Failure to Assess and Implement Elopement Risk Interventions
Penalty
Summary
The facility failed to adequately assess and implement measures to protect a resident identified as high risk for elopement upon admission. The resident, who had diagnoses including cognitive communication deficit, type II diabetes, metabolic encephalopathy, acute kidney failure, and an anxiety disorder, was admitted with a history of restlessness, aggressiveness, and a prior elopement attempt. Despite these risk factors, the resident's care plan and progress notes did not include any focus or interventions related to elopement risk, and there was no completed elopement assessment in the medical record prior to the incident. On the night of the incident, a CNA discovered the resident missing from their room during rounds, with a window open and evidence suggesting the resident exited through it. The facility initiated a search and notified appropriate parties. Documentation revealed conflicting assessments regarding the resident's elopement risk, with one assessment indicating high risk and another indicating no risk. The staff involved, including the nursing supervisor and LPNs, provided inconsistent information about the completion and content of elopement risk assessments. Interviews with facility leadership confirmed that the expectation was for all new admissions to be assessed for elopement risk and for interventions to be implemented if risk was identified. The facility's own policy required a systemic approach to monitoring and managing residents at risk for elopement, including assessment and person-centered care planning. However, these procedures were not followed for this resident, resulting in the failure to provide adequate supervision and accident hazard prevention as required.