Failure to Prevent Resident Elopement Due to Inadequate Window Security and Risk Assessment
Penalty
Summary
A resident with diagnoses including paranoid schizophrenia, COPD, anxiety, hypertension, and type 2 diabetes mellitus, who was noted to be confused and have severe cognitive impairment, was able to elope from the facility through a window. The window in the resident's room was not properly secured with a screw on the top track, which allowed the resident to lift and open the window, remove the screen, and exit the building. The maintenance supervisor later confirmed that the window did not have the required screw, and that all windows should have been secured to prevent such incidents. The facility failed to thoroughly and accurately assess the resident's risk for elopement. The elopement evaluation completed at admission did not identify the resident as being at risk, and staff did not interview the responsible party, who later reported that the resident had a history of elopement from other facilities. The assessment relied on the resident's own denial of elopement history, despite the resident's severe cognitive impairment, and did not include input from the responsible party or a review of prior incidents. Additionally, the facility did not monitor the resident's known triggers for elopement, such as confusion and agitation, as outlined in the care plan. Staff interviews revealed that behaviors related to elopement risk were not actively monitored, and staff were unaware of the need to check window security. The resident was last seen by a roommate, who observed the resident leaving through the window, and staff only became aware of the elopement after being alerted by another resident.