Failure to Prevent Elopement and Injury of High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a high risk for elopement was able to leave the facility without staff knowledge. The resident, who had diagnoses including dementia, Parkinson's disease, anxiety, depression, bipolar disorder, psychotic disorder, schizophrenia, and PTSD, was assessed as a high elopement risk according to the facility's own assessment tool. Despite this, the resident was last seen by staff in the early morning hours and was later found by a nearby business lying on the ground, having sustained a fractured left arm. The resident was transported to the hospital for evaluation and treatment. The facility's elopement protocol required identification of residents at risk for elopement, use of door alarms, and regular testing of these alarms, as well as staff training on elopement procedures. On the day of the incident, staff did not hear any door alarms, and the resident was not located during initial searches of the building. Interviews and observations revealed that a service entry/exit door in the kitchen area did not have an alarm, and a key was left hanging by the door, which may have allowed the resident to exit undetected. Staff interviews indicated that the resident was last seen in the dining room and at the nurse's station, but there was a gap in supervision that allowed the resident to leave the secured unit. The resident was found outside the facility by a staff member who had joined the search after being notified of the missing resident. The resident was lying on the ground, wet, and complained of pain in the left arm. The incident report and interviews confirmed that the required supervision and environmental safeguards were not sufficient to prevent the resident's elopement and subsequent injury. The facility's failure to ensure all exit doors were properly alarmed and monitored contributed to the resident's ability to leave the premises unnoticed.