Failure to Prevent Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to implement adequate interventions to prevent an elopement for a resident identified as high risk for elopement. The resident, who had severe cognitive impairment, dementia with behavioral disturbances, and a history of wandering and exit-seeking behaviors, was found off facility grounds in a supermarket parking lot by a CNA. The facility was unaware that the resident had left until notified by the CNA, who encountered the resident while off duty. The last known sighting of the resident within the facility was approximately an hour before the elopement was discovered. The facility's policies required elopement risk assessments and care planning for residents at risk of wandering or elopement. Although the resident's assessments and progress notes documented exit-seeking behaviors and a risk for elopement, the comprehensive care plan did not include a focus or interventions specifically addressing elopement risk. Additionally, there were gaps in monitoring at the front door, which was the exit point used by the resident. The front door was only alarmed with an audio alert during certain hours, and the pager system used to notify staff of door openings was not functioning correctly, only indicating the front door regardless of which door was opened. Staff interviews revealed that pagers were often ignored due to this malfunction, and there was not always staff present to monitor the front door. Observations during the survey also found that alarms on other doors were sometimes deactivated for convenience, and not always promptly reactivated, leaving those exits unmonitored. Staff interviews confirmed that the resident frequently wandered, especially in the afternoons, and that staff relied on informal methods to redirect him rather than consistent, documented interventions. The lack of a current, active care plan for elopement risk and the failure to ensure functioning alarm systems and adequate supervision directly contributed to the resident's ability to leave the facility undetected.