Failure to Provide Appropriate Dementia Services and Elopement Prevention
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate services for a resident diagnosed with mild dementia, agitation, and anxiety disorder, who was assessed as high risk for elopement. The resident repeatedly attempted to leave the facility, triggering personal alarms on multiple occasions and requiring staff intervention to prevent elopement. Despite the resident's ongoing exit-seeking behavior, staff responses were limited to escorting the resident back inside and attempting to re-educate him, which was noted as unsuccessful due to cognitive impairment. Documentation indicated that the resident's exit-seeking had increased in frequency, yet interventions remained largely unchanged and were not consistently documented. Further contributing to the deficiency, not all staff had received dementia training as required by facility policy, and some were unfamiliar with the location or use of the elopement logbook, which is essential for tracking and preventing unsafe wandering. The facility's own policy mandates a multi-faceted approach to elopement prevention, including staff education and awareness of procedures, but interviews revealed gaps in staff training and knowledge. These failures resulted in inadequate implementation of interventions and monitoring for a resident at high risk for elopement.