Failure to Prevent Elopement and Complete Smoking Safety Assessments
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder, a history of numerous elopement attempts, and an identified risk for elopement was able to leave the facility without staff knowledge. The resident had a WanderGuard device attached to her wheelchair, as she had previously removed the device from her person multiple times. Despite being on 15-minute supervision checks, there was no evidence that these checks were completed on the day of the incident. The resident was able to exit the facility when a visitor used a code to open the locked front door, and she left her wheelchair and the attached WanderGuard in the lobby before walking out unaccompanied. The resident walked approximately 0.2 miles to a local carryout, traversing a sidewalk with broken concrete and rocks along a busy five-lane road. Staff were unaware of her absence until a CNA, who was on a lunch break, happened to find her sitting on the floor of the carryout about 35 minutes after she had left the facility. At the time, the resident was actively hallucinating and expressing delusional thoughts. Documentation and interviews confirmed that staff did not perform or document the required 15-minute supervision checks on the day of the elopement, and staff were not aware the resident had left until notified by the CNA who found her. Additionally, the facility failed to complete required admission and quarterly smoking safety assessments for two residents who smoked, as mandated by facility policy. These assessments are necessary to determine if residents can smoke unsupervised or require safety measures. The lack of timely assessments placed these residents at risk for potential harm, as their ability to safely smoke was not evaluated upon admission or at required intervals.