Failure to Prevent Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including Alzheimer's Disease, was able to leave the facility unsupervised. The resident, who was awaiting discharge and had a BIMS score indicating severe cognitive impairment, was found outside the facility in his wheelchair, in a grassy area near a main road, during rainy weather. The incident was captured on video by a passerby and posted to social media, and the facility was first alerted to the resident's absence by a phone call from the passerby. Review of the resident's records showed that, although he was assessed as cognitively impaired with decreased safety awareness and disturbances in judgment, his elopement risk assessment did not indicate a risk for elopement, and his baseline care plan did not document a history of wandering or elopement. The care plan did note the need to evaluate for unsteady gait and maintain a safe environment. Staff interviews revealed that the resident was discovered outside by a housekeeper on break, who then called for help. A CNA responded and, along with the housekeeper, brought the resident back inside. The facility did not know the resident was missing until notified by the passerby. Interviews with facility staff, including the DON, BOM, and Administrator, confirmed that the resident was outside unsupervised and that staff were unaware of his absence until external notification. The resident was assessed after being brought back inside and was found to have no injuries. The deficiency was cited under F689 for failure to provide adequate supervision to prevent accidents, resulting in a successful elopement.