Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents, specifically in the case of a resident with severe cognitive impairment and a high risk for wandering or elopement. The resident, who had diagnoses including Neurocognitive Disorder with Lewy Bodies, COPD, and Diabetes Mellitus, was able to leave the facility in a wheelchair without staff awareness. The resident was found by a kitchen staff member on a driveway ramp near a busy street, and staff were unaware that the resident was missing until the kitchen staff returned the resident to the unit. The facility's policy required immediate action if a resident was found missing, but this was not followed as staff did not notice the resident's absence. Record reviews confirmed that the resident had a high score on the facility's Wandering Risk Scale and required supervision and permission to be outside. Interviews with staff and review of progress notes indicated that the resident regularly demonstrated exit-seeking behaviors and that the incident occurred without staff knowledge. The Director of Nursing and Administrator confirmed that the resident was confused, required supervision, and that staff were unaware of the resident's exit and location at the time of the incident.