Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a BIMS score of 2 out of 15 and a diagnosis of moderate dementia with behavioral disturbances, was admitted to the facility. The initial elopement risk evaluation did not identify the resident as an elopement risk, but subsequent assessments and care plan updates noted a history of attempts to leave the facility unattended, impaired safety awareness, and verbalized intent to go home. Despite these risk factors, the resident was able to leave the facility without staff knowledge on two separate occasions. On one occasion, the resident was noticed missing after having spent most of the day outside. Staff initiated a search, contacted local law enforcement, and found the resident returning to the facility after having walked to a store. On another occasion, the resident was again found missing, and staff discovered the resident's wanderguard device on the floor of the resident's room. After a search and notification of police, the resident was located walking on a main street and brought back to the facility. The resident refused a full body skin assessment upon return. Observations during the survey confirmed that the resident continued to spend time outside, often accompanied by 1:1 staff supervision. Interviews with the resident and the resident's representative confirmed the resident's preference for being outdoors and the facility's ongoing efforts to monitor and supervise the resident. The facility's failure to prevent the resident from leaving the premises without staff knowledge, despite known risk factors and previous incidents, constituted a deficiency in providing adequate supervision and ensuring the environment was free from accident hazards.