Failure to Prevent Resident Elopement and Incomplete Post-Incident Investigation
Penalty
Summary
A deficiency occurred when a resident with a history of Parkinson's disease, dementia, and other significant medical conditions exited the facility unsupervised. The resident had previously demonstrated wandering behaviors, including not staying in bed or in his room, and had a documented history of wandering at home. Despite these behaviors, the facility's assessments identified the resident as low risk for wandering and did not implement a wandering or elopement care plan. The resident's care plan focused on fall prevention, with interventions such as a bed and chair alarm, but did not address the risk of elopement. On the night of the incident, the resident was able to leave the building through an exit that was not alarmed at the time. Staff discovered the resident missing only after he had already exited, and he was found outside the facility with minor injuries. The bed alarm intended to alert staff was not sounding, and staff were unable to confirm if it had been activated. The facility's elopement and wandering policy required systematic identification, assessment, and monitoring of residents at risk for elopement, but these procedures were not fully followed in this case. Following the incident, there was no comprehensive assessment or thorough investigation documented. The facility did not collect staff statements or conduct a root cause analysis, and the investigation was not included in the resident's medical record. The lack of a timely reassessment and care plan update after the resident's wandering behaviors, as well as the absence of a complete investigation after the elopement, contributed to the deficiency.