Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of depression and bipolar disorder was able to elope from the facility through the back door. The resident, who utilized a wheelchair and had a BIMS score indicating severe cognitive impairment, was found on the street attempting to go to a gas station across from the facility, which is located near a busy highway. The resident sustained a skin tear to his arm during the incident. Documentation shows that the resident's care plan identified him as being at risk for wandering and required the use of a wander guard bracelet, with interventions including monitoring the bracelet's placement and function, and observing the resident's location each shift. Despite these interventions being documented, the resident was able to leave the facility unsupervised. The elopement risk assessments completed prior to the incident did not indicate imminent risk, and there were no additional elopement risk assessments found in the resident's health chart. Staff interviews revealed that while staff were generally aware of elopement protocols and the use of wander guard systems, several staff members were unaware of the specific incident or did not recall details about the resident's elopement. The door through which the resident exited was equipped with a wander guard alarm system, which was observed to be functional at the time of the survey, but it is unclear from the report how the resident was able to exit undetected. The incident was documented in clinical notes and an accident/incident report, which described the resident's elopement and subsequent return to the facility. The resident's family was notified, and the event was reported by staff. The deficiency centers on the facility's failure to provide adequate supervision and ensure the effectiveness of assistance devices to prevent the resident's elopement, as required by the resident's care plan and facility policy.