Failure to Accurately Assess Elopement Risk on Admission
Penalty
Summary
The facility failed to ensure the accuracy of a resident's assessment upon admission, resulting in the resident not being identified as at risk for elopement. The resident, who was admitted with diagnoses including dementia, muscle weakness, and generalized anxiety disorder, had a documented history of wandering as noted in the hospital discharge records. However, the facility's admission assessment did not reflect this history, instead documenting that the resident was disoriented but had not attempted to leave prior residences and did not wander. As a result, the resident was assigned a low elopement risk score and was not provided with a wander guard. The resident was placed in a first-floor room, and subsequently exited the facility unescorted after being buzzed out by the receptionist. Interviews with facility staff revealed that the admissions process involved reviewing the resident's medical history and physicals, but the Director of Nursing who completed the assessment did not recall seeing documentation of wandering in the hospital records. The failure to accurately assess and document the resident's elopement risk led to the omission of necessary safety measures, such as the use of a wander guard and appropriate room placement.