Failure to Prevent Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision, monitoring, and preadmission risk assessment to prevent a resident from exiting the facility unsupervised and without staff awareness or intervention. The resident, who had been admitted the previous day with diagnoses including unspecified dementia and altered mental status, was able to leave the building through the front door after the receptionist released the door lock. The receptionist did not recognize the resident as a new admission and allowed her to exit unaccompanied. The resident was later found approximately 600 feet from the facility, seated on a trailer in a public intersection surrounded by traffic, and was described as combative and yelling that she wanted to go home. Interviews with staff revealed that several employees, including LPNs, the DON, the Administrator, and CNAs, responded after hearing shouting and ran outside to retrieve the resident. None of the staff interviewed witnessed the actual elopement, only the aftermath. The receptionist confirmed that she had unlocked the door for the resident, not realizing she was a new admission, and the resident's representative stated she had told the receptionist to let the resident out, also not realizing the resident was new. The facility's policy required all residents to be assessed for wandering risk prior to or upon admission, but the assessment did not identify the resident's history of wandering as reported by the family. Further review indicated that the facility's process for identifying and monitoring residents at risk for wandering was not fully implemented for this resident. The Social Services Director had not yet added the resident to the wandering binder due to being off work at the time of admission, and the nurse who completed the assessment attributed the resident's confusion to a urinary tract infection, not being aware of the family-reported wandering history. The lack of effective communication and monitoring allowed the resident to exit the facility unsupervised, resulting in a situation determined to be Immediate Jeopardy and Substandard Quality of Care.