Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease and severe cognitive impairment successfully eloped from the facility. The resident, who was mobile with a device and had diagnoses including Alzheimer's Disease, hyperlipidemia, hypertension, and atherosclerotic heart disease, was admitted with a BIMS score of 6 out of 15, indicating severe cognitive impairment. The resident's Elopement Risk Assessment on admission noted cognitive impairment and wandering behaviors, but did not indicate a risk for elopement, and the Baseline Care Plan did not document a history of wandering or elopement. The incident was discovered when a passerby observed the resident alone outside in a wheelchair, in a grassy area near a main road, during rainy weather. The passerby contacted the facility, and staff were alerted to the resident's absence. A housekeeper on break noticed the resident in a ditch and called for help, at which point a CNA assisted in returning the resident to the facility. The facility was unaware of the resident's absence until notified by the passerby, and staff interviews confirmed that the resident was alone outside and unaccounted for until this external notification. The facility's policy on abuse, neglect, and exploitation requires protection of residents' health, welfare, and rights, including the identification, assessment, care planning, and monitoring of residents with behaviors that might lead to neglect. In this case, the failure to identify and address the resident's risk for elopement, combined with a lack of monitoring, resulted in the resident leaving the facility unsupervised and being exposed to potential harm.