Failure to Implement Elopement Precautions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement adequate supervision and accident prevention measures for a resident with severe cognitive impairment and a known risk of elopement. Upon admission, the resident was identified as being at risk for elopement through an assessment completed by an LPN. Despite this assessment, the required elopement precautions were not implemented. These precautions included notifying the physician and responsible party, placing a wander guard device on the resident, and updating the care plan to reflect the elopement risk. The resident's baseline care plan only included general interventions for cognitive loss and did not address the specific risk of elopement. On the day of the incident, the resident was last seen by a CNA after being escorted to her room. Later, the resident's daughter arrived and discovered that her mother was missing. Staff initiated a search, including a head count and checking all rooms, but were unable to locate the resident. The police were notified, and the resident was eventually found by law enforcement approximately two miles from the facility, having crossed a four-lane divided highway. The resident was returned to the facility and assessed by EMS, with no physical injuries noted. Interviews with facility staff revealed that the LPN who completed the elopement risk screening did not believe the resident was at risk, despite the assessment indicating otherwise. The LPN acknowledged that none of the required elopement precautions were implemented. The director of nursing confirmed that the elopement screening can be completed by floor nurses or the MDS nurse, and that all nurses are expected to follow the policy for residents identified as high risk for elopement. The failure to implement these precautions resulted in the resident being unsupervised and able to leave the facility without detection.