Failure to Investigate and Address Elopement After Unsupervised Off-Site Appointment
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough investigation and take corrective action after a resident with a known elopement risk left supervision during an off-site dental appointment. The resident had diagnoses including schizophrenia/schizoaffective disorder, major depressive disorder, and moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12. According to the resident’s family member, the resident experienced hallucinations and exhibited poor and impulsive decision-making, making him vulnerable when left unattended. The facility’s appointment calendar for the dental visit specifically documented in capital letters that staff were to stay with the resident due to elopement risk and noted that his sister would arrive shortly after the scheduled appointment time. On the day of the dental appointment, a staff member transported the resident and was aware that the resident was not to be left unsupervised. The staff member waited until the resident was escorted to the exam room, then left the office to pick up paperwork from another facility, believing the resident would be safe while with the dentist. When the staff member returned, dental staff reported that the resident had already left. The resident’s whereabouts were unknown for approximately one hour, during which time he left the dental office alone, obtained a taxi, and traveled to a relative’s home approximately two miles away. The facility-reported incident documented that the resident refused to return to the facility and expressed a desire to live on his own and to travel out of state to visit friends. Following the elopement event, facility leadership acknowledged that no Interdisciplinary Team (IDT) review, after-action plan, or full investigation was completed regarding the resident’s elopement from the dental office. Staff stated that aside from the facility-reported incident form, they did not document the sequence of events from the time the resident was left unsupervised at the dental visit to the time he was located, nor did they determine or document corrective actions. This lack of investigation and documentation occurred despite the facility’s written Elopement policy, which required the IDT to investigate elopement incidents, identify contributing factors and root causes, and document findings and recommendations in the medical record with updates to the plan of care as indicated.
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