Failure to Prevent Elopement of High-Risk Resident from Secure Unit
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and multiple psychiatric and neurological diagnoses, including non-Alzheimer's dementia, psychotic disorder, schizophrenia, and Parkinsonism, was not adequately supervised and eloped from a secure unit. The resident had a documented history of wandering and was assessed as high risk for elopement, with care plan interventions specifying placement on a secure neighborhood and a goal of no elopement episodes. However, the care plan form did not delineate specific interventions, and the resident was observed wandering the halls, expressing a desire to leave, and was later found missing from the unit. Staff were unable to locate the resident during routine rounds, and a search of the unit and facility grounds was initiated. The resident was eventually found by bystanders nearly a mile from the facility, appearing confused and lying in the grass, and was attended by EMS, police, and fire department personnel. The LPN retrieved the resident from EMS care and returned them to the facility, noting minor injuries such as skin tears to both hands and an elevated temperature due to the hot weather. The resident's physician was notified of the incident after the resident's return. Interviews and documentation revealed that the resident likely exited the secure unit through a door that did not close completely or by following another person out, as the resident did not have the capacity to use the keypad code. The facility's disaster plan for elopement was not fully implemented at the time of the incident, and there was a delay in notifying the physician and administration. The lack of specific care plan interventions and inadequate supervision contributed to the resident's ability to leave the secure unit and the facility grounds.