Failure to Maintain Accurate Elopement Risk Documentation and Supervision
Penalty
Summary
The facility failed to implement and maintain up-to-date interventions to mitigate the risk of elopement for a resident with significant cognitive impairment. The resident in question had diagnoses of dementia, depression, and traumatic brain injury, and was assessed as being at risk for elopement based on a recent increase in their elopement risk assessment score. The resident's care plan included the use of a WanderGuard bracelet, 15-minute visual checks, and specific monitoring instructions. Despite these interventions, the resident was able to exit the facility when a transportation company opened the door, indicating a lapse in supervision and monitoring. Staff relied on an Elopement Risk Book at the nurse's stations to identify residents at risk for elopement, but the book was not kept current. Observations and interviews revealed that the Elopement Risk Book contained outdated information, lacked resident photos and face sheets, and had discrepancies regarding which residents were currently at risk or had active WanderGuard devices. Staff members were unclear about which residents were at risk and who was responsible for updating the book, with some staff unaware of recent elopement incidents and the current status of the elopement risk documentation. The facility's policy required that each resident's risk for elopement be assessed upon admission and that a photo and face sheet be placed in the Elopement Risk Book. However, these requirements were not consistently followed, as evidenced by missing photos and outdated lists in the risk books at both nurse stations. This failure to maintain accurate and current elopement risk documentation contributed to the increased risk of elopement for residents identified as at risk.