Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent an elopement for one resident. The resident, an elderly male with diagnoses including encephalopathy and epilepsy, had severely impaired cognition as indicated by a BIMS score of 05. He required supervision and/or set-up assistance for care and used a walker and wheelchair for ambulation. Despite being assessed as low risk for wandering or elopement, the resident was able to leave the facility undetected between 11:30 PM and 12:00 AM. The resident was discovered missing during routine rounding at midnight by a CNA, who then alerted the nurse and initiated the facility's elopement protocol. The resident was found approximately 0.1 miles away at a nearby hospital and was returned to the facility by an LVN around 12:30 AM. Upon return, the resident was assessed and reported no pain or injuries. There was no documentation of previous wandering behaviors or prior elopement attempts for this resident. Interviews with facility leadership confirmed that all residents were expected to remain in the building for safety reasons, but it was unclear how the resident was able to elope. The facility's records indicated that doorways were checked and that the resident was subsequently placed on 1:1 monitoring. The incident was discussed among the physician, administrator, and DON, and the facility's policies on elopement management and abuse prevention were reviewed.