Failure to Implement Elopement Interventions Leads to Resident Leaving Facility
Penalty
Summary
The facility failed to implement care plan interventions for a resident with a known history of elopement risk. The resident, who had Wernicke's encephalopathy and moderate cognitive impairment as indicated by a BIMS score of 8, was assessed as a wandering risk and was independent with ambulation. The care plan, revised prior to the incident, indicated the resident was insisting on leaving and had been placed on a secured dementia unit with increased visual checks. However, staff did not consistently perform or document the required rounds, with one CMA admitting to not conducting rounds at 3:00 a.m. and being unsure if any other rounds were done, instead spending most of the shift at the nurse's station watching television. The facility's policy required routine checks at least every two hours and more frequently for high-risk residents, but this was not followed for the resident in question. As a result of these lapses, the resident was able to leave the facility unsupervised and was later found by police on the side of the road, complaining of leg pain and weakness, and was transported to the hospital. Upon return, the resident was noted to have healing abrasions on both shins. Interviews with staff and review of video footage confirmed that staff did not follow the care plan interventions or facility policy for increased supervision and rounding for residents at high risk for elopement.