Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for one resident. According to the facility's policy, residents at risk for wandering or elopement should have specific interventions in place, including orders for a wander guard, regular checks of the device, and quarterly elopement assessments. The resident in question, who had diagnoses of heart failure, diabetes, and cerebral infarction, was assessed as moderately cognitively impaired with a BIMS score of 9. Despite this, the resident's initial elopement evaluation indicated no risk, and appropriate interventions were not implemented. The deficiency was identified when the resident was found outside the facility in the parking lot with her belongings packed, after contacting her husband to pick her up. The receptionist observed the resident outside and assisted her back into the building, notifying nursing staff. At the time of the incident, the resident did not have a wander guard in place, and her care plan lacked resident-specific interventions to address elopement risk. Interviews with the DON and Nursing Home Administrator confirmed that the care plan did not include required checks for the wander guard or battery, and failed to provide adequate supervision to prevent the elopement.