Failure to Assess and Prevent Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to accurately assess a resident for elopement risk, did not provide appropriate interventions to prevent elopement, and did not implement new interventions after repeated incidents. The resident in question had a history of Parkinson's Disease, traumatic brain injury, and schizo-affective disorder, and was admitted with a care plan that allowed for independent outdoor activity. Despite documentation indicating the resident required supervision or assistance with mobility, the admission assessment incorrectly stated the resident was not at risk for elopement, as it was believed the resident could not exit the facility independently. The resident was able to leave the facility without staff knowledge or the use of assistive devices on two separate occasions. On one occasion, the resident exited the building without signing out or notifying staff, and on another, the resident was found by police sitting in the road outside the facility. After the first incident, the resident was not reassessed for elopement risk, and no incident or accident report was completed as required by facility policy. The care plan was not updated to reflect the resident's actual risk or to implement new interventions after these events. Interviews with the DON confirmed that the initial assessment was inaccurate and that the resident's known history of independent exits from previous living situations was not properly considered. The facility's failure to reassess the resident after the first elopement, to complete required documentation, and to update the care plan or implement further interventions directly contributed to the repeated elopement incidents.