Failure to Prevent Elopement for Resident with Cognitive Impairment and Behavioral Health Needs
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent elopement for one of three residents identified as being at risk for elopement. The resident in question had a history of traumatic brain injury, psychotic disorder with delusions, alcohol dependence with alcohol-induced dementia, and moderate cognitive impairment, as evidenced by a BIMS score of eight out of 15. The resident was independent in activities of daily living and had a documented pattern of wandering and exit-seeking behaviors, including a history of elopement from other facilities. The care plan identified the resident as an elopement risk and included interventions such as secure unit placement, monitoring, and redirection from exits. Despite these interventions, the resident was able to elope from the facility. On the evening of the incident, the resident was last seen during routine building rounds and was later found missing during the next round. Facility staff initiated a search and notified appropriate parties, including the DON, NHA, physician, and local police. The resident was located off facility grounds by staff, noted to have a strong odor of alcohol, and returned to the facility. Interviews and documentation revealed that the resident was able to climb over the perimeter fence by using tension wires as footholds, exploiting a physical vulnerability in the facility's security measures. The facility's security cameras did not capture the elopement due to a blind spot. Staff interviews confirmed that the resident had previously expressed a desire to leave the facility, particularly after interactions with family members, and that the facility was conducting 15-minute checks on residents. The resident's agitation increased after a phone call with his mother on the day of the elopement. The facility's elopement and wandering policy required assessments and individualized care planning for residents at risk, but the measures in place were insufficient to prevent the resident from leaving the premises unsupervised.