Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with a history of elopement, vascular dementia, chronic paranoid delusions, bipolar disorder, and psychosis exited the facility unsupervised. The resident was assessed as an elopement risk, refused to wear a wander guard bracelet, and was known to wander throughout the facility. Despite interventions such as diversional activities, quarterly elopement assessments, and staff supervision, the resident was able to leave the facility through the front entrance when a staff member was entering the building. The resident was later found across the street at a gas station, sitting on a bench and smoking a cigar. The resident reported leaving the facility to relieve neuropathy discomfort by walking and did not understand why walking alone was not permitted. Staff interviews revealed that a housekeeper observed the resident exiting the building but did not immediately report the incident or follow the resident, as required by facility policy. The housekeeper was distracted by an emergency phone call and only later reported seeing the resident exit when questioned by the administrator. The facility's elopement policy defines elopement as a patient leaving the facility unnoticed and unsupervised, which occurred in this case. Documentation confirmed that the resident was allowed to leave only with a specific family member and with conservator permission, which was not the case during this incident.