Failure to Implement Elopement Precautions for High-Risk Resident
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to implement required elopement precautions for a resident identified as high risk for elopement upon admission. The resident, who had severe cognitive impairment as indicated by a low BIMS score and diagnoses including vascular dementia, was assessed as being at risk for elopement during the admission process. Despite this assessment, the LPN did not notify the physician or the resident's representative, did not apply a wander guard device, and did not update the care plan to reflect the resident's elopement risk, as required by facility policy. The resident subsequently eloped from the facility by following visitors out the front door while unsupervised. The absence of elopement precautions allowed the resident, who was ambulatory and severely cognitively impaired, to leave the premises without detection. Staff only became aware of the resident's absence after the resident's daughter reported her missing, prompting a facility-wide search and notification of the police. The resident was found by police approximately two miles from the facility, having crossed a four-lane divided highway. Interviews with facility staff confirmed that the LPN responsible for the initial assessment did not believe the resident was at risk for elopement, despite the positive screening, and therefore did not implement the required interventions. The director of nursing identified the failure to implement elopement precautions as the root cause of the incident.