Failure to Follow Elopement Policy and Timely Care Planning for Community Pass Privileges
Penalty
Summary
The facility failed to follow its policies and procedures to ensure the safety and supervision of a resident who was on a supervised community pass. Specifically, the facility did not contact the police to assist in locating the resident when he did not return at the indicated time, as required by their elopement policy. Staff attempted to reach the resident and his family by phone but did not escalate the situation to law enforcement after the two-hour grace period had elapsed. Multiple staff members were unclear about the policy for contacting the police, and communication was limited to internal notifications and calls to emergency contacts. Additionally, the facility did not complete a risk for elopement assessment for the resident upon admission, as mandated by their own elopement policy. The assessment was only completed several days after admission, leaving a gap in identifying and addressing potential elopement risks. The resident had a history of major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder, and was considered cognitively intact but required supervision with activities of daily living. Furthermore, the facility did not initiate a person-centered care plan to address the resident's community pass privilege in a timely manner. Although a physician's order for outside pass privileges was obtained, the corresponding care plan was not started until several days later, beyond the expected timeframe. This delay in care planning meant that the interdisciplinary team did not have timely guidance to address the resident's needs and potential risks associated with community outings.