Failure to Supervise Elopement-Risk Resident Who Left Facility Unnoticed
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and provide adequate supervision for a resident identified as at risk for elopement. The resident was admitted with end stage renal disease and had moderately impaired cognition per the MDS. A care plan dated late November indicated the resident was at risk of elopement related to wanting to go home or leave the facility, with directions to continue monitoring for elopement risk behaviors and to reassess elopement risk as needed. A progress note from early December documented that the resident was discussed in IDT due to being identified as an elopement risk based on history. Despite this identified risk and care plan, the resident left the facility without staff knowledge or a Leave of Absence order and walked to a local coffee shop unaccompanied. A progress note from early January documented that staff saw the resident at the coffee shop and brought the resident back, and that the resident verbalized persistent desires to go home and was still requesting discharge. During interviews, the p.m. shift nurse stated that the facility was notified by an off-duty staff member around mid-afternoon that the resident was at the coffee shop, after which a code for a missing resident was initiated and the resident was returned within about 30 minutes. The DON confirmed that staff did not know when the resident left the facility and could not provide an exact time of departure, and that the resident had no LOA order and did not notify staff when leaving. A CNA reported finding the resident sitting on a bench at the coffee shop and stated the walk from the facility to the coffee shop was approximately 15 minutes. The facility’s wandering and elopement policy stated that residents at risk for wandering or elopement would be identified and their care plans would include strategies and interventions to maintain safety.
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