Failure to Monitor and Document Whereabouts of High-Risk Resident Resulting in Elopement and Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to monitor and document the hourly whereabouts of a resident identified as high risk for elopement, as required by the resident's care plan. The care plan specified that the resident, who had a history of elopement and impaired safety awareness, should be monitored every hour. However, documentation in the Point of Care Response History showed that staff did not consistently check or record the resident’s whereabouts every hour, with significant gaps between documented checks. Staff interviews confirmed that the resident was last seen in her room in the evening, but was later discovered missing, and staff were unable to determine when or how she exited the facility. The resident involved had diagnoses including schizophrenia, anxiety disorder, and major depressive disorder, and was assessed as having moderate cognitive impairment and the ability to walk. She had a prior history of elopement from the facility. On the night of the incident, staff last observed her in her room, but she was later found to be missing. Despite a search of the facility and notification of the DON and police, the resident was not located until the following morning, when she was found by police approximately a mile away from the facility, exposed to cold weather conditions and without shoes. Medical evaluation after the incident revealed that the resident suffered from hypothermia, leukocytosis with left shift, and metabolic acidosis, requiring hospitalization. The facility’s policy required systematic monitoring and management of residents at risk for elopement, including regular assessment, care planning, and supervision, but these measures were not effectively implemented in this case. Staff interviews and documentation review confirmed that the required hourly monitoring was not performed or recorded as specified in the care plan, directly contributing to the resident’s unsupervised exit and subsequent medical complications.