Failure to Prevent Elopement and Ensure Safe AMA Discharges
Penalty
Summary
The facility failed to implement appropriate interventions to prevent elopement and did not act effectively when elopement occurred for two residents identified as at risk. One resident, with a history of leaving healthcare facilities against medical advice (AMA) and documented risk factors for elopement, expressed a desire to leave upon admission. Despite recommendations to implement care plan interventions and consider a wander bracelet, these measures were not put in place, and the care plan did not address the resident's elopement risk. The resident subsequently eloped from the facility. Another resident, admitted for a hip fracture and anxiety disorder, was not assessed for elopement risk and was found missing after signing out to retrieve a wheelchair. The resident did not return as expected, and staff were initially unaware of their whereabouts, with staff later acknowledging that elopement protocol should have been followed. The facility also failed to ensure safe discharges for residents leaving AMA. For one resident with congestive heart failure and cirrhosis, documentation showed the resident left AMA without receiving their stored medications or having them sent to a pharmacy. The medical record did not reflect efforts to encourage the resident to stay, nor was there a completed Release of Responsibility form as required by facility policy. Another resident, dependent on oxygen and diagnosed with chronic obstructive pulmonary disease, requested to leave AMA, but the medical record lacked the required Release of Responsibility form and did not document actions taken to ensure a safe discharge. Facility policy requires that residents leaving AMA be educated on the risks, that the attending physician be notified, and that all efforts to ensure a safe discharge be documented, including completion of a Release of Responsibility form. In the cases reviewed, these steps were not consistently followed, and documentation was incomplete or missing, failing to demonstrate that the facility made reasonable efforts to ensure the safety of residents leaving AMA.