Failure to Investigate Elopement Incident for High-Risk Resident
Penalty
Summary
The facility failed to thoroughly investigate an incident of elopement involving a resident with severe cognitive impairment and a history of wandering. The resident, who had a diagnosis of dementia, a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment, and was identified as high risk for wandering, was found outside the building unattended. The resident was wearing a Wanderguard, and facility policy defined elopement as any resident leaving the campus without informing staff. Despite this, the incident was not reported as an elopement, no incident report was completed, and no detailed notation was made in the resident's medical record as required by facility policy. Interviews with facility staff confirmed that the resident should not have been outside unattended and that the Wanderguard system was the only safeguard in place to prevent such incidents. The Assistant Administrator stated that no investigation or assessment was conducted because the incident was not considered an elopement and there was no visible injury. The Director of Nursing was unaware of how long the resident was outside, and the Administrator later confirmed that the incident should have been investigated as an elopement but was not. The facility's reportable investigations for the past 12 months did not include any elopements, despite this event.