Failure to Implement Elopement Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when a newly admitted resident with severe cognitive impairment, Alzheimer's disease, and dementia, who was identified as being at high risk for both falls and elopement, was not provided with adequate supervision or safety interventions. Upon admission, assessments documented the resident's high risk for elopement and falls, citing factors such as recent admission, disorientation, confusion, inability to communicate needs, and a history of wandering. Despite these documented risks, the resident's care plan did not include elopement or fall prevention interventions until after the resident had already eloped from the facility. Staff interviews and documentation revealed that although the need for a wanderguard device was identified, it was not applied because the admitting nurse did not know where the devices were kept or how to activate them, and believed it was the nurse manager's responsibility. The nurse manager was informed of the risk but left the facility, assuming the device would be applied later. Other staff members, including nurses and nursing assistants, were either unaware of the resident's risk status or did not know what the resident looked like, and increased safety checks were not implemented prior to the incident. The lack of communication and training regarding elopement prevention measures contributed to the failure to supervise the resident adequately. As a result of these failures, the resident was able to leave the facility unsupervised, travel through an attached assisted living area, cross a parking lot and a busy street, and was eventually found by police in a parking lot across the street. The facility's policy required individualized interventions for residents at risk of elopement, but these were not implemented in this case, leading to an immediate jeopardy situation.