Failure to Prevent Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, specifically failing to prevent the elopement of a cognitively impaired resident. The resident, who had a history of cerebral infarction, language disorder, heart failure, cardiomyopathies, aphasia, substance abuse, and confusion, was admitted to the facility and was noted by multiple staff members and family to be confused and cognitively impaired. Despite these observations, the resident's elopement risk assessment did not indicate cognitive impairment or identify the resident as an elopement risk. Staff interviews revealed inconsistent recognition of the resident's confusion and potential for elopement, with some staff considering the resident at risk and others not, based on the absence of exit-seeking behaviors at the time of admission. The resident was last seen in his room early in the morning and was discovered missing a few hours later. Upon searching, staff found a window open with the screen removed, indicating the resident had exited through the window. The facility did not have a plan in place for monitoring windows to ensure resident supervision and prevent such incidents. The lack of accurate assessment and monitoring contributed to the resident's ability to leave the facility undetected, and the resident was found 26 hours later at a family member's home, displaying agitation and confusion. Interviews with staff and family members highlighted gaps in communication, assessment, and supervision. Staff had received training on elopement assessments, but there was confusion about when to identify a resident as an elopement risk, particularly for new admissions with cognitive impairment but no immediate exit-seeking behavior. The facility's policy required identification and care planning for residents at risk of wandering or elopement, but this was not effectively implemented for the resident in question, resulting in the deficiency.