Failure to Prevent Elopement and Inadequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to prevent accidents and incidents for a resident with a high risk of elopement. The resident, who had diagnoses of schizophrenia and bipolar disorder with psychotic features, was assessed as cognitively intact but had a history of wandering, episodes of disorientation, and confusion. Despite being identified as high risk for elopement on a risk assessment, documentation inconsistently described the resident as only a moderate risk, and a wander guard was removed. The resident had a physician order for a wander guard to be in place and functioning, with staff directed to check its placement and function every shift. Multiple incidents occurred where the resident exited the building without staff knowledge, including being found outside by therapy staff and being brought back inside on two separate occasions after exhibiting aggressive behaviors. On another occasion, the resident exited the building by following another resident who had entered the security code to the front door, and was only noticed and assisted back inside by an LPN after about a minute. There was no documentation of incident reports or changes to interventions following these events, and the DON confirmed that no new interventions were implemented to prevent further unauthorized exits during this period.