Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with moderate dementia, diabetes, and unsteadiness on his feet was not provided with adequate supervision and assistance to prevent accidents, specifically elopement from the facility. The resident, who was ambulatory with a walker and had a BIMS score indicating moderately impaired cognition, was identified as being at risk for elopement following an incident where he exited the facility by pushing past visitors. Despite this, interventions such as visual checks and care plan updates were implemented only after the initial elopement attempt. On a subsequent occasion, the resident was again able to leave the facility unsupervised. Staff became aware of the resident's absence after a family member, monitoring a camera in the resident's room, called to report that the resident was not visible. A systematic search was conducted, and the resident was eventually found by police near train tracks, having suffered severe hyperthermia and acute hypoxic respiratory failure, requiring hospitalization and intubation. The resident's care plan had included interventions for exit-seeking behavior, but these measures did not prevent the second elopement. Interviews with staff and review of records revealed that the resident had expressed distress about his family being away and concerns about his farm, which may have contributed to his exit-seeking behavior. The facility's risk assessment initially did not identify the resident as high risk for elopement, and the care plan interventions were not sufficient to prevent the resident from leaving the building on two separate occasions. The deficiency was identified as having placed the resident at risk for serious harm, as evidenced by the resident's hospitalization following the elopement.