Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with dementia and a traumatic brain injury from eloping from the facility. The resident was identified as being at risk for elopement based on an Elopement Evaluation and had a care plan in place that addressed this risk, including a history of wandering and previous elopement at a hospital. The resident's Minimum Data Set assessment indicated impaired cognitive status, and the care plan specifically noted the need for supervision due to alcohol/drug-seeking behavior and elopement risk. Despite these documented risks and care plan interventions, the resident was able to leave the facility unsupervised and undetected. Staff became aware of the resident's absence after being informed by another staff member, and the resident was missing for approximately one hour before being located. Facility policy required adequate supervision for residents at risk of elopement, but this was not implemented as indicated in the resident's care plan. Interviews with facility staff and the administrator confirmed the resident's high risk for elopement and acknowledged that closer supervision should have been provided.
Plan Of Correction
The preparation and/or the execution of this plan of correction do not constitute admission of agreement by the provider of true facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because the provisions of the Federal and State law require it. This Plan of Correction constitutes the facility's credible allegation of compliance. Corrective action accomplished for identified resident(s) affected by the deficient practice: Resident 1 was found and brought back into the facility without incident or injury. Resident placed on 1 on 1 supervision until the wanderguard system for the front door was adjusted with an additional reader on 10/3/2025. How other residents having potential to be affected by the same deficient practice will be identified and what corrective action will be taken: On 10/2/2025, an audit of all residents that triggered at risk for elopement was completed by the Medical Records Director to ensure that they all have appropriate interventions in place. Updates made as identified. Immediate measures and systemic changes put in place to ensure that the deficient practice does not recur: On 10/1/2025 and 10/2/2025, the Director of Staff Development in-serviced CNAs and Licensed Nurses on the elopement policy and procedure and wanderguard devices. A description of the plans and persons responsible for monitoring ongoing performance, and ensuring that the corrective actions are achieved and sustained: The Medical Records Director or designee will conduct an audit for residents triggering as elopement risks weekly to confirm interventions are in place. The results of the audits will be reported to the QAPI Committee meeting monthly for 3 months and then re-evaluated thereafter. Completion Date: 11/4/2025