Failure to Prevent Elopement and Provide Adequate Supervision for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent accidents for a resident with severe cognitive impairment and a known history of exit-seeking behaviors. The resident, diagnosed with Alzheimer's disease, non-Alzheimer's dementia, and a psychotic disorder, had a BIMS score indicating severe cognitive impairment and was assessed as high risk for wandering. Despite multiple documented incidents of the resident attempting to exit or successfully eloping from the facility, the care plan addressing elopement risk was not created until after the first elopement and was not updated following subsequent incidents. The resident was able to leave the facility on several occasions, including escaping through the front door and being found walking down a nearby highway and in the facility lawn. Staff interviews and documentation revealed that doors could be opened by holding them for a period of time, and staff were aware of the resident's risk but did not consistently implement or document increased supervision or interventions. There were also gaps in the documentation of required 15-minute checks following elopement incidents, and staff reported not receiving specific training related to elopement prevention or response. Other residents and staff confirmed that multiple residents exhibited wandering or exit-seeking behaviors, and that the facility's doors, while coded, could be bypassed. The facility lacked a specific elopement policy, relying instead on a missing persons policy, and staff responses to elopement incidents were inconsistent. The infection control nurse identified several residents at risk for elopement, but there was no evidence of systematic involvement of the facility's QAPI process in addressing these incidents.