Failure to Assess and Intervene After Resident Elopement
Penalty
Summary
A resident with a history of severe cognitive impairment, including a brain tumor, cognitive communication deficit, and memory impairment, was admitted to the facility. The resident's records indicated difficulty following directions and a need for maximum cues. Despite these documented cognitive deficits and a known tendency to wander, the resident was able to exit the building without staff authorization and was later found at a liquor store by facility staff. Review of the resident's medical records revealed there was no documented evidence of an elopement care plan, elopement risk assessment, or change of condition assessment following the incident. Interviews with facility staff, including a licensed nurse, the Social Services Director, and the Administrator, confirmed that the facility did not assess or implement interventions for the resident's elopement risk as required by facility policy. Additionally, there was no documentation of the incident or follow-up actions in the resident's record, contrary to the facility's elopement and missing resident policy.