Failure to Assess and Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to ensure the highest practicable well-being of a resident who was at risk for elopement. Specifically, the Director of Nursing (DON) did not ensure that nursing staff conducted a risk for elopement assessment at the time of the resident's readmission, and elopement precautions were not implemented. The charge nurse responsible for the admission assessment, which includes the elopement risk assessment, did not complete this assessment and was unaware that it was required at readmission. As a result of these failures, the resident was able to leave the facility unsupervised. The resident exited through the facility's locked front door with the Medical Director and was left unattended on the front porch. The resident then walked along a busy four-lane road without supervision and entered a nearby dental office. The facility was notified by the dental office staff, and the resident was retrieved and returned to the facility by therapy staff. The last observation of the resident in the facility was in the day area, and the elopement was discovered when the dental office contacted the facility. Interviews with facility staff confirmed that the required elopement risk assessment was not completed at readmission, and there was a lack of awareness and oversight regarding the policy for such assessments. Both the DON and the Administrator acknowledged their responsibility for policy oversight and staff education, including training on admission and elopement assessments. The failure to assess and supervise the resident placed the resident at risk and resulted in an Immediate Jeopardy situation.