Failure to Timely Reassess Elopement Risk Following Change in Resident Condition
Penalty
Summary
The facility failed to timely reassess a resident's risk for elopement and wandering following significant changes in the resident's condition and mobility status. The resident, who had diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, and a history of falls, was initially assessed as non-ambulatory and not at risk for elopement. However, subsequent physical therapy assessments documented progressive improvement in ambulation, with the resident eventually able to walk up to 100 feet with minimal assistance. Despite these changes, the resident's elopement risk was not reassessed as required by facility policy. Over several days, nursing notes documented the resident exhibiting agitation, wandering within their room and into other residents' rooms, and difficulty with redirection. The resident was also involved in an incident with a roommate, which led to a temporary hospital transfer. Upon return, the resident continued to display wandering behaviors and increased mobility, but no updated elopement or wander risk assessment was completed during this period. The deficiency culminated when the resident eloped from the facility after being left unattended for a brief period. The resident was found outside the building and returned without injury. Review of facility documentation and interviews confirmed that a reassessment of elopement risk should have been conducted when the resident began exhibiting increased mobility, agitation, and wandering behaviors, but this was not done in a timely manner.