Failure to Assess and Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to ensure that residents at risk for elopement were properly assessed and that physician-ordered interventions were implemented to prevent possible elopement. Three residents with significant medical and psychiatric histories were identified as being at risk for elopement, but deficiencies were found in their care and supervision. For one resident, the care plan included the use of a wander prevention device as ordered by a physician, but observation revealed the device was not in place, and staff confirmed the resident would remove and discard the device. The system did not alert staff when the resident was at the door, and the Director of Nursing acknowledged the absence of the device. Another resident, identified as high risk for elopement, did not have a care plan addressing this risk, and the required quarterly elopement risk assessments were not completed as per facility protocol. Staff interviews confirmed that the resident had previously attempted to leave the facility by removing a window and that the resident would not keep a wander prevention device on. The resident was subsequently moved to a different room, but documentation of ongoing risk assessments was lacking. A third resident, also with a history of cognitive and behavioral issues, was found to have a care plan and physician order for a wander prevention device, but the required quarterly elopement risk assessments were not completed. Staff interviews confirmed that these assessments were not being conducted as required. Additionally, the facility's elopement policy and protocol were not provided upon request. These findings demonstrate a pattern of inadequate assessment and failure to implement or maintain interventions for residents at risk of elopement.