Failure to Prevent Elopement of Resident with Dementia
Penalty
Summary
The facility failed to ensure the safety of a resident with dementia by not effectively managing elopement risks. Specifically, the Nursing Home Administrator (NHA) and Director of Nursing (DON) did not establish or maintain systems to ensure that elopement assessments were completed correctly, nor did they prevent residents exhibiting elopement behaviors from leaving the facility without proper supervision. This lapse in management and oversight resulted in a resident eloping from the facility, creating an Immediate Jeopardy situation. Review of job descriptions and facility policies indicated that both the NHA and DON were responsible for developing and implementing operational policies and procedures to meet residents' needs and ensure their safety. However, documentation and staff interviews revealed that these responsibilities were not fulfilled, as evidenced by the failure to complete elopement assessments and to supervise residents at risk for elopement. The resident involved had a diagnosis of dementia, which increased their vulnerability, and the lack of appropriate interventions directly led to the elopement incident.