Failure to Prevent Resident Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident with multiple risk factors, including end stage renal disease, unspecified dementia, repeated falls, and impaired mobility. The resident, who used a wheelchair or scooter and was cognitively impaired, was able to independently ambulate and had a history of confusion and memory loss. Despite these risks, the resident was able to leave the facility without staff knowledge or supervision on two separate occasions. On one occasion, the resident was found attempting to cross a four-lane street with a posted speed limit of 50 mph, and on another, the resident was located at an apartment complex across the street after being missing for a period of time. The facility's records and staff interviews revealed that there were no elopement risk assessments completed for the resident prior to the second incident, and no interventions or increased supervision were in place despite the resident's known cognitive impairment and previous attempt to leave the premises. Staff failed to recognize or respond to the resident's elopement risk, and there was a lack of communication and documentation regarding the incidents. Multiple staff members, including nurses and the receptionist, were unaware of the resident's risk for elopement and did not have clear protocols for monitoring or restricting the resident's movements. Interviews with staff and administration indicated inconsistencies in the recognition and reporting of the elopement events. Some staff were unaware of previous incidents, and there was confusion about whether the events constituted reportable elopements. Incident reports were not completed for any of the occurrences, and there was no evidence of a thorough investigation or timely notification to facility leadership. The lack of appropriate assessment, supervision, and response to the resident's behavior directly led to the resident being able to leave the facility unsupervised on multiple occasions.