Failure to Accurately Assess and Monitor Elopement Risk
Penalty
Summary
The facility failed to accurately complete an elopement assessment for a resident with a history of frequent elopement from home, as documented by both a hospital discharge report and a caregiver statement. Despite clear evidence that the resident had previously eloped and was missing for several days prior to admission, the facility's elopement assessment incorrectly indicated no such history. The Social Services Director confirmed that the resident was not included in the elopement monitoring system due to this error, and the nurse responsible for the assessment did not document the resident's known elopement risk. Facility policy required that all residents be assessed for elopement risk upon admission and throughout their stay, but this was not followed in this case.