Failure to Identify and Respond to Potential Elopement
Penalty
Summary
The facility failed to identify and appropriately respond to a potential elopement when a resident's empty wheelchair was found on the facility curb during rainy weather. The resident, who had diagnoses including peripheral vascular disease, manic depression, and psychotic disorder, was known to leave the building without signing out despite prior education and care plan interventions. The resident's care plan directed staff to encourage independence while monitoring behaviors, but on the day of the incident, staff discovered the resident's empty wheelchair outside and brought it back inside without immediately locating the resident. The resident was later returned to the facility by another resident in a vehicle, and staff notified the executive director and the resident's guardian after the fact. Medical record review indicated the resident had intact cognition but required staff assistance for wheelchair mobility. Staff interviews revealed that the expectation was for residents to sign out when leaving and for staff to initiate the elopement process if a resident was unaccounted for. However, in this instance, the elopement process was not initiated when the resident was missing, and the facility was unaware of the resident's whereabouts until their return. The facility's policy defined elopement as leaving the premises without authorization or necessary supervision, particularly when the facility is unaware of the resident's departure.