Failure to Assess and Intervene After Resident Elopement Attempts
Penalty
Summary
A cognitively impaired resident with a history of alcohol-induced dementia, falls, and other significant medical conditions expressed a desire to leave the facility and made two attempts to exit through a back door. Despite these attempts and clear verbalization of wanting to go home, there was no reassessment of the resident's elopement risk, and no elopement care plan or interventions were implemented at that time. The resident's care plan did not include elopement precautions until several days after the initial exit attempts. Subsequently, the resident was able to exit the facility unnoticed, wearing only a hospital gown and pushing a wheelchair, and was found outside the building by staff after being unsupervised for approximately 10-15 minutes. Documentation of the incident was inconsistent, with initial notes indicating only an attempt to leave, and no addendum was made to reflect that the resident had actually left the building. The Director of Nursing and Nursing Home Administrator initially denied that an elopement had occurred and were unable to provide evidence regarding the resident's whereabouts or the duration of time spent outside. Further investigation revealed that the facility's front entrance was left unmonitored for periods of time, and the security camera system was nonfunctional, preventing verification of the incident. There was no investigation into the elopement, and the facility failed to follow its own elopement policy, which required risk assessments upon significant changes and after incidents. The lack of timely assessment, intervention, and supervision resulted in the resident's unsupervised exit from the facility.