Failure to Prevent Elopement and Ensure Adequate Supervision
Penalty
Summary
A resident with severe cognitive impairment and a history of wandering was admitted to the facility and assessed as being at moderate risk for elopement and high risk for falls. Despite these assessments, no care plan was developed to address the resident's risk for elopement. The resident initially had a sitter provided by the family, but this service was discontinued after a few days, and there was no documented evidence that alternative supervision or safety interventions were implemented. On the day of the incident, the resident was observed walking in the hallway and entering another resident's room. Shortly after, staff discovered the resident was missing, initiated a search, and notified the police. The facility had multiple exits leading to public streets, none of which were alarmed, and did not have a wander guard or alarm system in place. Review of monitoring logs revealed inconsistent documentation, with several missing entries and at least one instance where a CNA documented monitoring the resident during a period when the resident was actually missing. The resident was found the following day in the neighborhood by a citizen, exhibiting altered mental status and physical injuries, including hypothermia, multiple abrasions, a forehead laceration requiring sutures, and rhabdomyolysis. The facility's policies on care planning and wandering/elopement did not adequately address preventative measures, and staff interviews confirmed that required care planning and monitoring were not consistently performed.