Failure to Provide Adequate Supervision and Elopement Prevention for High-Risk Resident
Penalty
Summary
A resident with a diagnosis of secondary malignant neoplasm of the brain and severe cognitive impairment, as indicated by a BIMS score of 7, was admitted to the facility. Upon admission, the resident was assessed using the facility's Wander Risk Assessment and was determined to be at high risk for wandering. Despite this high-risk score, the resident's Baseline Care Plan did not include any interventions for wandering or elopement, and management was not notified of the resident's high elopement risk. On the day of the incident, the resident was last seen in the facility in the late afternoon and was later discovered missing when medication was to be administered in the evening. Staff initiated a search of the building and grounds, and law enforcement and emergency services were notified when the resident could not be located. The resident was eventually found at a nearby apartment complex and transported to the emergency room, where he was treated for minor injuries sustained from a fall but did not require hospitalization. Interviews with facility staff revealed that there was confusion regarding the interpretation and follow-up of the wandering risk assessment. The nurse who completed the assessment did not believe the resident was exit-seeking and did not obtain a history from the family. There was no specific policy in place for actions to be taken after a resident was identified as high risk for elopement, and the process for notifying management and implementing interventions was not followed. The lack of communication and failure to update the care plan with appropriate interventions contributed to the resident's elopement.