Failure to Prevent Elopement Due to Inadequate Assessment and Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for a resident with multiple medical conditions, including moderate cognitive impairment. Upon admission, the resident was not initially assessed as being at risk for elopement, despite having a BIMS score of 4 and exhibiting wandering behavior. The resident was later identified as at risk for elopement after a reassessment, and interventions such as inclusion in the Elopement book and 15-minute checks were implemented. However, there was inconsistency in the risk assessments and care plan updates, as a subsequent assessment overrode the high-risk status without proper reflection in the care plan. The resident was able to exit the facility through the front door after 4 PM, reportedly with the assistance of the receptionist, despite being on 15-minute checks and listed in the Elopement book. At the time, two facility entrances were locked after 4 PM, while the others required a security code, but there were no Wander Guards or security cameras in place. Staff interviews revealed that monitoring relied primarily on 15-minute checks and staff awareness, with no electronic monitoring devices used for residents at risk of elopement. The facility's policy required the environment to remain as free of accident hazards as possible and for residents to receive adequate supervision and assistive devices to prevent accidents. Despite these policies, the resident was able to leave the facility unsupervised, and staff acknowledged that adequate protection was not provided after the resident's elopement risk was identified.