Failure to Assess Elopement Risk at Admission Resulting in Resident Elopement
Penalty
Summary
The facility failed to assess a resident for elopement risk factors upon admission, as required by facility policy. The resident, who had a history of cerebral infarction, impaired cognition, and alcohol abuse, was admitted without a completed Nursing Admission Evaluation to determine elopement risk. The Minimum Data Sheet indicated the resident had severely impaired cognition, and the facility's policy required that an elopement risk assessment be completed at admission. However, the assessment was not performed until 41 days after admission. As a result of this omission, the resident was able to leave the facility unsupervised in a wheelchair and was found by a staff member approximately 1,000 feet from the facility. The staff member returned the resident to the facility, and a Wander Guard was applied afterward. Interviews with staff confirmed that the elopement risk assessment was not completed as required, and the administrator acknowledged the failure to follow policy regarding timely assessment at admission.