Failure to Complete Timely Elopement Risk Assessments for Cognitively Impaired Resident
Penalty
Summary
Staff failed to complete an accurate and timely assessment for a resident identified as being at risk for elopement. The resident, who had severe cognitive impairment and multiple complex medical and psychiatric diagnoses, was documented as exhibiting frequent wandering behaviors and episodes of agitation, hallucinations, and delusions. Despite these ongoing behaviors and the resident's care plan identifying elopement risk, the required Elopement Risk Evaluations were not completed quarterly or as needed, as per facility protocol and standards of practice. The clinical record showed that after an initial Elopement Risk Evaluation was completed in March, no further evaluations were documented until August, despite multiple progress notes indicating continued and escalating wandering and behavioral symptoms. Both the MDS coordinator and the DON acknowledged that the evaluations were overdue and should have been completed in accordance with the facility's policy. The deficiency was identified through clinical record review and staff interviews, confirming that the resident's assessments were not conducted as required.