Failure to Prevent Resident Elopement Through Window
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, bipolar disorder, and delusional disorders broke a window in her room, exited the building, and was found lying on a bench in the staff smoking area approximately 30 minutes after being noted missing. The resident had a history of severely impaired cognition, as indicated by a BIMS score of 07, but had not previously exhibited exit-seeking behavior or attempted to elope. At the time of the incident, the resident was ambulatory with a walker and independent in most activities of daily living. The resident's care plan identified her as being at risk for wandering, with interventions in place to monitor and intervene as appropriate. However, on the day of the incident, staff last observed the resident rearranging items in her dresser before leaving to administer medication to another resident. Upon returning, the staff member found the resident missing and discovered the broken window. The resident was located outside in a gated courtyard area, having used furniture to break the window and exit the building. She was assessed and found to have no injuries, though she refused to re-enter the building and was subsequently transported to the hospital for evaluation. Interviews with staff and review of records confirmed that the resident had not previously demonstrated behaviors indicating a risk for elopement, and her most recent elopement risk assessment had classified her as low risk. Staff reported that the resident was generally pleasant, enjoyed social interaction, and had frequent family visits. The incident was unexpected, and staff responded by searching the facility and locating the resident within 30 minutes of her being found missing.