Failure to Prevent Elopement and Inadequate Supervision for Residents with Exit-Seeking Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent elopement for residents with known exit-seeking behaviors. One resident, admitted with dementia and a history of a femur fracture, was initially assessed as low risk for elopement. However, over several months, this resident exhibited repeated exit-seeking behaviors, including multiple documented attempts to leave the facility, both alone and with another resident. Despite these behaviors, the only intervention documented prior to the incident was redirection, which was repeatedly noted as ineffective. No additional interventions were added to the care plan, and the resident was not reassessed for wandering risk as required by facility policy. Another resident, also with severe cognitive impairment and a diagnosis of Alzheimer's disease, was assessed as a moderate risk for wandering upon admission. This resident also demonstrated exit-seeking and wandering behaviors on multiple occasions, but there was no documentation of reassessment for wandering risk or the addition of elopement prevention interventions to the care plan prior to the incident. Staff interviews confirmed that hourly location checks and redirection were the only interventions used, and these were discontinued after a short period without further action. Staff also reported a lack of knowledge regarding identification of residents at risk for elopement and appropriate interventions. The deficiency culminated in an incident where the first resident was able to exit the facility through a laundry room door that was supposed to be locked, resulting in a fall and injury outside the building. The facility's own policy required regular reassessment for wandering risk and the implementation of additional interventions for residents exhibiting exit-seeking behaviors, but these steps were not taken. The DON and administrator acknowledged that the residents were not reassessed or care planned appropriately, and that the door used for elopement was not secured as required.