Failure to Identify and Supervise Elopement Risk Resulting in Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and did not identify a resident as an elopement risk, resulting in the resident eloping from the unit. Upon admission, the resident, who had diagnoses of dementia, anxiety, and bipolar disorder, was assessed by an LPN and not identified as an elopement risk, despite being disoriented, having memory impairment, and being ambulatory with assistance. The elopement risk assessment was not fully completed, and no elopement care plan was initiated for the resident. Staff interviews revealed that the resident was confused, attempted to get into other residents' beds, and was mobile in a wheelchair, but these behaviors were not recognized as indicators of elopement risk. The resident was last seen on the unit before being found missing, and staff did not immediately follow the facility's elopement policy, including calling a code green as required. The resident was eventually found in the basement, uninjured, after being missing for approximately thirty minutes. The facility's admission process also failed to identify that the resident had previously resided in a secured memory care unit at another facility, and the necessary precautions were not taken upon admission. The staff responsible for the admission assessment did not receive a proper handoff or report from the hospital or family, and the RN Supervisor did not assist with the assessment. Further review indicated that the facility's elopement risk assessment tool was inadequate, as it did not identify residents who were at risk for elopement if they were not ambulatory at the time of admission. The admissions director acknowledged that the process sometimes missed risk factors, and the facility did not reassess the resident for elopement risk when her mobility increased. Additionally, the facility did not ensure that all staff were educated on elopement risks and supervision, and the required procedures were not consistently followed when the resident was found to be missing.