Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A resident with diagnoses including schizoaffective disorder, hypertension, dementia without behavioral disturbances, and bipolar disorder was admitted to the facility and assessed as having severely impaired cognition. The resident was identified as high risk for elopement, with an elopement evaluation and care plan in place that included interventions such as redirection, distraction, prompt response to alarms, and restrictions on leaving the unit. Despite these interventions, the resident exhibited repeated exit-seeking behaviors, including attempts to open doors, pushing on exit doors, and trying to jump a fence in the smoking area. Staff notes documented multiple incidents where the resident attempted to leave the facility, and on one occasion, another resident succeeded in opening a door, nearly allowing the high-risk resident to exit. On the day of the deficiency, the resident continued to aggressively seek exits, and staff interventions, including non-pharmacological measures and administration of medications, were not effective in preventing these behaviors. The resident was on frequent staff checks but was not placed on one-on-one supervision despite escalating behaviors. Later that day, the resident successfully eloped from the mental health unit, triggering an alarm. Staff were unable to determine the direction the resident had taken, and a search was initiated. The resident was found approximately one hour later, hiding in bushes about 50 feet from the facility, and was returned without injury. Interviews with staff, including an LPN and the DON, confirmed that the resident had not been placed on one-on-one supervision until after the elopement occurred, despite multiple prior attempts to leave and clear documentation of high elopement risk. The facility's elopement policy was found to only address procedures following an elopement, not preventive measures. This sequence of events demonstrates a failure to provide adequate supervision and interventions to prevent the elopement of a resident assessed as high risk.