Failure to Prevent Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
A deficiency occurred when a resident with dementia, who was admitted for hospice respite care and was severely cognitively impaired, was able to elope from the facility. The resident was independently ambulatory, had a history of wandering, and required supervision, as documented in multiple progress notes and care plans. Despite these documented risks, the resident's elopement risk assessment was scored as zero, indicating no risk, even though the assessment noted wandering behaviors. The facility did not have a wander guard system, and the front doors were not locked. On one occasion, the resident attempted to elope but was stopped by a nurse. The following day, the resident successfully exited the facility by leaving with a church group and was later found at a nearby store across a two-lane street and near a four-lane highway. Staff interviews revealed that the resident was missing for approximately 10-20 minutes before being located and returned to the facility. Documentation and staff statements confirmed that the resident was not properly identified as an elopement risk, and interventions such as increased supervision or physical barriers were not implemented prior to the incident. Interviews with staff and review of records indicated lapses in communication and assessment. The night nurse was not informed of the resident's wandering behaviors by the previous shift, and the Assistant Director of Nursing was unaware of the resident's elopement attempt until after the successful elopement. The facility's elopement policy required identification and care planning for residents at risk, but these procedures were not followed, resulting in the resident's unsupervised exit from the facility.