Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with a history of severe cognitive impairment and high risk for wandering was able to leave the facility unsupervised and travel approximately three miles, crossing heavily trafficked streets, before being returned by local police. The resident, who had a BIMS score of 3/15 indicating severely impaired cognition and diagnoses including an unspecified mental disorder and chronic obstructive pulmonary disease, resided on an unsecured unit and had a documented history of wandering within the facility. Despite these risk factors, the resident's care plan did not address her ability to exit the facility alone, did not include interventions for wandering, and did not specify how often her whereabouts should be checked. On the day of the incident, the resident was observed by the facility's CFO exiting and re-entering the building multiple times in the morning, with the final exit occurring at 10:03 AM. No staff member was aware that the resident had left the facility, and her absence went unnoticed until the CFO received a call from the resident's friend at 12:49 PM, informing her that the resident was at her former apartment and that the police were returning her to the facility. Interviews with staff revealed that the last known sighting of the resident was around 9 AM, and staff did not realize she was missing until notified by an external party. The resident did not sign out or have a family member or friend accompany her, as required for a leave of absence. Review of the resident's records showed that while she was assessed as high risk for wandering, no elopement risk assessments were completed, and her care plan lacked specific interventions for her wandering behavior. Nursing notes prior to the incident documented episodes of the resident being lost within the facility and expressing intentions to leave, but these behaviors were not addressed with targeted interventions. The facility's policy required assessment and interventions to prevent elopement, but these were not implemented for this resident prior to the incident.