Failure to Accurately Assess Elopement Risk
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's risk for elopement. A review of the resident's physical therapy assessment indicated the resident was alert and able to ambulate with a front-wheeled walker, though with a slow gait and complaints of fatigue. The resident's medical history included acute myocardial infarction, coronary angioplasty, heart failure, COPD, and psychosis. The joint mobility screening showed full range of motion in all extremities. However, the elopement risk assessment documented that the resident could not walk or self-propel a wheelchair independently. Interviews with the Physical Therapy Director confirmed the resident could walk to the bathroom with minimal assistance but required frequent safety cues due to impulsivity. The Registered Nurse Supervisor, who completed the elopement risk assessment, based her assessment on limited observation and the resident's selective responsiveness, concluding the resident was non-ambulatory. The nurse later acknowledged the assessment was inaccurate and that the resident was at high risk for elopement. The facility's policy required comprehensive assessment upon admission to inform care planning, but this was not followed, resulting in the failure to identify and address the resident's elopement risk.