Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement risk for one of six residents. The resident, who had a diagnosis of anxiety and muscle weakness and was assessed as moderately cognitively impaired with a BIMS score of 12, was identified as being at risk for elopement according to the facility's own Elopement Evaluation Form. Despite this, the resident was able to enter the kitchen, an area not designated for residents, and take a tray and cups back to another floor. The dietary manager observed the resident in the kitchen, educated him about the safety concern, and escorted him back to his unit. Following the incident, the facility did not complete a physical assessment of the resident upon return to the unit, nor did they notify the physician or the resident's responsible party about the event. The Director of Nursing confirmed that the resident had a history of wandering and that the facility failed to provide adequate supervision to prevent the incident, as well as failing to complete the required assessments and notifications after the occurrence.