Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with dementia and a history of repeated falls. The resident, who had a moderately impaired cognitive status as indicated by a BIMS score of 7, was identified as an elopement risk based on a recent assessment. Despite this, there were no interventions in place on the care plan to address the risk of elopement prior to the incident. On the night of the incident, the resident was last seen in the hallway by staff at approximately 1:20 AM. Shortly after, the exit door alarm in the dining room sounded, but staff response was delayed and the alarm was reportedly not loud enough to be clearly heard by all staff. The resident was subsequently found outside the facility, face down in the parking lot, with a nosebleed and skin tears on her forehead and cheek. She was transported to the emergency department and returned a few hours later. Interviews with staff revealed that although the resident had been assessed as high risk for elopement, staff did not perceive her as exit-seeking prior to the event and interventions were not implemented until after the incident. The facility's policy required assessment and care plan modifications for residents at risk of elopement, but these steps were not taken in this case. The lack of timely and appropriate supervision, as well as insufficient alarm volume, contributed to the resident's unsupervised exit and subsequent injury.