Failure to Accurately Assess and Care Plan for Elopement Risk
Penalty
Summary
The facility failed to accurately complete an elopement risk assessment for a resident with severe cognitive impairment, alcohol-induced amnestic disorder, metabolic encephalopathy, and major depressive disorder. The resident, who was able to self-propel in a wheelchair and required assistance for daily activities, was found outside the facility after falling from his wheelchair, without staff knowledge. The resident had previously demonstrated behaviors indicating a desire to leave, such as pulling the facility fire alarm to go home, but the elopement risk evaluation did not reflect his cognitive deficits, history of substance abuse, or independent mobility. The resident's clinical record also lacked a care plan addressing elopement risk. On the day of the incident, the resident was last seen by staff around the nurses' station and was later found outside by emergency medical services after a bystander reported seeing him in the grass next to his wheelchair. The resident stated he had been let out by an unknown person and was attempting to go home. Staff interviews confirmed that the elopement risk assessment was not accurate, as it failed to account for the resident's cognitive and behavioral history, and the facility's policy required interdisciplinary review and care plan updates for elopement risk, which were not completed.