Failure to Prevent Elopement of At-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with a history of exit-seeking and elopement risk was able to leave the facility unsupervised. The resident, diagnosed with early onset Alzheimer's disease, anxiety, depression, and COPD, had recently been admitted and was assessed as at risk for elopement based on prior behaviors and assessment scores. Despite this, the resident was able to exit the building through a keypad-controlled door by entering the correct code, which was accessible due to a label indicating the code format. The resident left the facility at approximately 5:30 A.M. and was not discovered missing until 7:15 A.M. during a shift change, resulting in a significant delay before a search was initiated and law enforcement was notified. The resident's care plan included monitoring for sleep issues and mood, but there was no evidence of specific interventions to address the elopement risk beyond routine checks. Staff observations and documentation indicated the resident had been awake and in her room earlier in the morning, but there was no continuous supervision or targeted monitoring for exit-seeking behavior. The facility's policies required routine checks every two hours, but the resident was able to leave undetected between checks, and the absence of an alarm or notification system on the exit door further contributed to the failure to prevent the elopement. Interviews with staff and the resident's Power of Attorney revealed that the resident had memory issues and a desire to return to a previous home, which was a known risk factor. The resident was found by law enforcement approximately 1.2 miles from the facility, near a former residence, after being missing for several hours. The incident demonstrated a lack of adequate supervision and failure to implement effective interventions for a resident assessed as at risk for elopement, resulting in the resident's unsupervised departure from the facility.
Removal Plan
- Completed audits of clinical records for residents at risk for exit-seeking behavior or elopement.
- Removed labels indicating keycodes from keypads.
- Provided in-service training to staff on the elopement exit seeking policy and establishing interventions for residents assessed to be at risk for wandering/elopement.