Failure to Recognize and Report Resident Elopement
Penalty
Summary
The facility failed to recognize and report an elopement incident involving a resident identified as being at risk for elopement. The resident, who had a history of wandering and elopement attempts, was able to remove his WanderGuard bracelet using a fingernail file and left the facility without staff knowledge. He was gone for approximately an hour before being located by police and returned to the facility. The resident reported that he had previously eloped from the facility a couple of months prior, also by removing his WanderGuard, and was gone for about 20 minutes before staff noticed his absence. Review of the resident's medical record and facility incident reports revealed a lack of documentation regarding these elopement attempts. There were no risk management or incident reports related to the events, and the Minnesota Adult Abuse Reporting Center did not have any facility-reported incidents for the resident's elopement attempts. The resident's elopement risk assessment indicated multiple risk factors, including a history of wandering, family concerns, and medications that could cause confusion, but interventions in place were limited to recreational activities, a check-in/out log, staff awareness, room personalization, and a WanderGuard. Interviews with staff, including nursing assistants, an RN, the DON, and the administrator, confirmed that the resident was considered an elopement risk and that staff were aware of his tendencies. Despite this, the incident was not reported to the State Agency, as the facility's leadership did not initially consider the event to be an elopement. The facility's own policy defined elopement as a resident leaving the premises without authorization or necessary supervision, and required immediate reporting of such incidents, but this protocol was not followed.