Inaccurate Cognitive and Elopement Risk Assessment
Penalty
Summary
The facility failed to conduct an accurate assessment for a resident regarding cognitive skills for daily decision making. The resident, who had a history of bipolar disorder, diabetes mellitus, dysphagia, hypertension, and a below-knee amputation, was under a public conservatorship due to being unable to make legal, financial, medical, or care decisions. Despite this, the Minimum Data Set (MDS) assessment indicated the resident had intact cognition for daily decision making. Additionally, the Elopement Risk Assessment for the resident was completed with 'No' responses to all questions, as the tool was designed to assess elopement risk based on history at home, not within the facility. The Director of Nursing confirmed that the assessment did not account for the resident's current situation in the facility. The resident subsequently eloped from the facility, an event considered absence without leave (AWOL) by the public guardian, highlighting the inaccuracy of the assessments conducted.