Failure to Reassess and Intervene After Resident Expressed Intent to Leave
Penalty
Summary
A deficiency occurred when a resident, admitted with diagnoses including cirrhosis of the liver, chronic congestive heart failure, and hepatic encephalopathy, expressed a desire to leave the facility but did not receive appropriate interventions for elopement risk. The resident had previously been assessed as not at risk for elopement upon admission, with the initial evaluation indicating no verbalization of wanting to leave. However, on the day of the incident, the resident told RN 1 that he wanted to leave and go to a friend's house but was unable to provide an address. Despite this verbalization, RN 1 did not complete a new elopement risk evaluation as required by facility policy, nor were additional monitoring or interventions implemented. Subsequently, the resident was discovered missing from the facility, prompting staff to search both inside and outside the premises and in the surrounding community. The Director of Nursing confirmed that the facility's policy required a new elopement risk assessment and closer monitoring when a resident verbalizes intent to leave. The failure to reassess and implement interventions after the resident expressed a desire to leave resulted in the resident leaving the facility unsupervised.