Failure to Identify and Address Elopement Risk in Residents with Cognitive Impairment
Penalty
Summary
The facility failed to identify and address elopement risks for several residents as required by policy. Specifically, residents with cognitive impairments and behaviors such as exit-seeking and wandering were not consistently assessed for elopement risk upon admission, quarterly, or when there were significant changes in condition. For one resident with dementia and a BIMS score indicating moderate impairment, only one elopement risk screen was found in the record, and it was not updated despite ongoing behaviors such as fixating on going home and independently moving about the unit in a wheelchair. Staff interviews confirmed that these behaviors were not recognized as triggers for reassessment, and the required quarterly elopement risk screens were not completed. Another resident, also with dementia and a high elopement risk score on admission, did not have further elopement assessments completed as required. A third resident with dementia and a physician order for a wanderguard was observed without the device, and staff were unable to account for its absence. The Director of Nursing confirmed that the facility did not timely identify residents with behaviors triggering elopement risk, failed to assess them on an ongoing basis, and did not provide appropriate care plans or physician orders for interventions related to exit-seeking behaviors.