Failure to Prevent Elopement of Cognitively Impaired Resident During Hazardous Weather
Penalty
Summary
A deficiency occurred when a resident with a history of Alzheimer's disease, dementia, and paranoid personality disorder was not provided adequate supervision and was able to elope from the facility during hazardous winter weather. The resident had a documented history of exit-seeking behavior, impaired cognition, and poor safety awareness, and had previously required a wander guard device. However, the wander guard was discontinued after staff determined there were no recent exit-seeking behaviors, and the elopement risk was removed from the care plan. Despite this, the resident continued to display confusion, impulsivity, and had triggers related to the holiday season that were not adequately considered in risk assessments or care planning. On the day of the incident, the resident was last seen by staff in the facility's common area and was later found outside in a wheelchair, inadequately dressed for the severe weather conditions. The resident had expressed a desire to leave and was looking for his truck the evening prior, but this information was not effectively communicated between shifts. Staff interviews revealed that the resident required supervision due to his cognitive deficits and that staff were expected to check on him every two to three hours, but closer monitoring was not implemented despite recent exit-seeking behaviors. Documentation and communication failures contributed to the deficiency. The resident's care plan and elopement risk assessments did not reflect his ongoing risk factors, including his history of elopement, cognitive impairment, and seasonal behavioral triggers. Staff were unaware of the resident's increased risk and did not implement appropriate interventions or monitoring. The lack of timely reassessment and failure to update the care plan after the resident expressed exit-seeking behavior directly led to the resident's unsupervised exit during dangerous weather conditions.
Removal Plan
- A complete head to toe health assessment was completed for R1 upon return to facility
- R1's provider was updated
- An elopement assessment with past and recent risk for elopement was included
- A wander guard was placed on R1's wheelchair
- Reviewed and revised R1's care plan to ensure it included details related to holiday challenges, staff communication, behavioral tracking, and interventions for exit seeking
- Elopement assessment practices were reviewed and revised to best determine resident elopement risk, including consideration of history, mental health, seasonal challenges, and medication changes
- Nursing staff completing elopement assessments were retrained on recognizing and responding to exit seeking behavior
- All staff were trained on R1's care plan changes and facility policy changes
- Facility education document 'Critical Safety Alert: Elopement Prevention & Emergency Protocol' with mandatory interventions and communication requirements was issued