Failure to Prevent Elopement for Resident with Known Exit-Seeking Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was as free from accident hazards as possible and did not provide adequate supervision and assistance to prevent accidents for a resident with a known history of elopement and wandering. The resident, who had diagnoses including encephalopathy, intracranial injury, muscle weakness, paranoid schizophrenia, recurrent depressive disorders, cerebral infarction, and anxiety disorder, was admitted with a baseline care plan identifying them as an elopement risk and requiring placement in a secure unit. The resident's admission and subsequent elopement assessments documented cognitive impairment, a history of elopement, and exit-seeking behaviors, with recommendations for increased supervision and consideration of electronic monitoring devices. Despite these documented risks and interventions, the resident was able to obtain the code to the secure unit and eloped from the facility. The incident occurred when staff were occupied in different areas of the unit, with one CNA monitoring residents in the lounge and another providing a shower to a different resident. The resident left the facility in a wheelchair and was found by a member of the public across the street, unable to provide a coherent statement and expressing a desire to go to his mother's house. The facility's records indicate that staff were aware of the resident's risk factors and that interventions such as frequent monitoring and staff awareness of wandering behavior were in place, but these measures were insufficient to prevent the elopement. Interviews with staff confirmed that elopement in-services and drills were conducted, and that staff were instructed to be vigilant when residents were near the exit door and to avoid entering the code if a resident was present. However, on the day of the incident, these precautions did not prevent the resident from leaving the secure unit. The deficiency was identified as past noncompliance, with the event constituting a failure to provide adequate supervision and to implement effective measures to prevent elopement for a resident with a known history of such behavior.