Failure to Prevent Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with severe cognitive impairment. The resident, who had diagnoses including unspecified intracranial injury with loss of consciousness, hepatitis C, and liver cirrhosis, was assessed as having a BIMS score of 6, indicating severe cognitive impairment. Despite this, the resident was not identified as being at risk for elopement on the facility's risk evaluation. The clinical record did not document any wandering or elopement behaviors, yet a Wander Guard was ordered and in use for the resident. The care plan noted impaired cognitive function and interventions to cue, reorient, and supervise as needed. On the day of the incident, the resident was found outside the facility in front of the building by a staff member, and was immediately brought back inside. A subsequent check revealed that one exit door was not secure, while the remaining doors were locked. The Nursing Home Administrator and Director of Nursing confirmed that the facility did not provide adequate supervision to prevent the resident's elopement.