Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to provide adequate supervision to prevent a cognitively impaired resident from eloping. The resident, who had diagnoses including mild neurocognitive disorder with behavioral disturbance and cognitive communication deficit, was admitted with two physician certificates indicating incapacity to make medical decisions. Initial assessments did not identify the resident as an elopement risk, but subsequent BIMS assessments showed moderate to severe cognitive impairment. Nursing progress notes documented behaviors such as refusing care, agitation, wandering, exit seeking, and safety concerns, but no interventions were implemented to address these behaviors. On the morning of the incident, the resident was observed to be agitated, attempting to leave, and even tried to break a window. Staff were notified of the resident's behavior, and a GNA was asked to monitor the resident, but was not assigned to provide one-to-one supervision. The resident was able to access the elevator and reach the kitchen area, where dietary staff mistook the resident for a visitor and allowed them to exit the building. Staff interviews confirmed that the resident did not appear to be a resident and was able to leave the facility without proper verification of identity. The facility's investigation determined that staff failed to recognize and appropriately supervise a resident with exit-seeking behaviors, resulting in the resident eloping from the facility. The resident was later found by police at a gas station several miles away and returned to the facility after a hospital evaluation. The deficiency was attributed to the lack of effective supervision and failure to implement measures to address the resident's documented behaviors and risks.