Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent an accident involving a resident with a known history of wandering and high risk for elopement. The resident, who had Alzheimer's disease, severe cognitive impairment, and a high elopement risk score on admission, was able to exit the facility unsupervised by following a visitor out the front door. Staff were unaware that the resident had left the building and only discovered her absence when she was found outside by another staff member approximately 20 minutes later. The resident was ambulatory with a walker and was found standing on the sidewalk, having exited the facility without staff knowledge or intervention. The care plan for the resident included interventions for wandering and elopement risk, such as distraction, monitoring for exit-seeking behavior, and notification of the charge nurse if such behavior was observed. However, staff interviews revealed that those assigned to the resident were not aware of her high risk for elopement or the specific interventions in her care plan. Staff monitoring was conducted every two hours, but there was no increased supervision or targeted monitoring for elopement risk, despite the resident's assessment indicating a high risk. Additionally, staff did not consistently check care plans or elopement risk scores to inform their supervision practices. Facility policies required elopement risk assessments on admission and with changes in condition, as well as care plan modifications and interventions for residents at risk. Despite these policies, the resident was able to leave the facility undetected, and staff did not recognize or respond to her exit in a timely manner. The event was only discovered after the resident was found outside, and the facility was not aware of her absence until that point. The failure to implement and communicate appropriate supervision and interventions for a high-risk resident led to the deficiency.