Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safety and prevent the elopement of a resident who was assessed as being at risk for elopement. The resident, who had diagnoses including unspecified dementia, unspecified mood disorder, unsteadiness on feet, and required assistance with personal care, was severely cognitively impaired as indicated by a BIMS score of 3/15. Despite being identified as an elopement risk and having a care plan that included interventions such as alarms and monitoring, the resident was able to leave the facility premises unnoticed by staff. The resident was last seen by staff approximately 15 minutes before being found outside the facility, walking along a road without a sidewalk, by a staff member who happened to be driving by. Multiple staff interviews revealed that the resident had a known pattern of exit-seeking behaviors, including frequently checking doors, setting off alarms, and expressing a desire to leave the facility for cigarettes or to see white cars. Staff also reported that the resident's behaviors would escalate, but there was no documentation or consistent monitoring of these behaviors in the resident's medical record prior to the elopement event. Although the facility had a blanket behavior monitoring order for all residents, it was not individualized or specific to the resident's known behaviors. Communication about the resident's increased exit-seeking behaviors was primarily verbal and not consistently documented or shared with all staff. There was no evidence of behavior logs or specific interventions being implemented or documented in response to the resident's escalating behaviors prior to the incident, which contributed to the failure to prevent the elopement.