Failure to Reassess and Supervise Resident with Exit-Seeking Behaviors Resulting in Elopement and Injury
Penalty
Summary
A deficiency occurred when the facility failed to accurately assess, reassess, and provide adequate supervision and safety monitoring for a resident with moderately impaired cognition and a lack of safety awareness. The resident, who had a history of anxiety, depression, cognitive decline, and required assistance with activities of daily living, exhibited behaviors such as confusion, hallucinations, anxiety, and exit-seeking. Despite these behaviors, the resident's elopement risk assessment was not updated, and their care plan was not revised to reflect the increased risk. The facility's policy required identification and care planning for residents at risk of unsafe wandering or elopement, but this was not followed in this case. The resident was placed on 1:1 supervision and every 15-minute checks at times when they were actively exhibiting exit-seeking behaviors, but this increased supervision was discontinued when the resident appeared calmer, without a documented reassessment of risk. Staff interviews revealed inconsistent awareness and communication regarding the resident's elopement risk, with some staff unaware of the resident's status and the resident not being listed in the facility's elopement risk communication binder. On the night of the incident, the resident was able to exit the facility unsupervised through a window, and staff did not immediately recognize the resident was missing. There was no overhead emergency code called, and the resident was not located until found by staff from a neighboring assisted living facility. As a result of the lack of updated assessment, care planning, and supervision, the resident was found outside the facility, lying on the ground, cold, agitated, and with injuries including a head injury, left elbow fracture, and multiple bruises, requiring hospital evaluation and intervention. The incident report and staff interviews confirmed that the required processes for monitoring, reassessment, and communication of elopement risk were not followed, directly leading to the resident's unsupervised exit and subsequent harm.