Failure to Implement Elopement and Fall Prevention Interventions for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify and care plan a resident’s elopement risk and fall risk, and to implement interventions to prevent accidents. The facility had an Elopement/Exit Seeking policy stating it would provide a safe and secure environment and be proactive in preventing elopement. The resident involved had a history of traumatic brain injury, unspecified mood disorder, history of falling, inattention, disorganized thinking, depression, and exhibited wandering behaviors that significantly interfered with care and put others at risk for physical injury. The resident’s care plan documented impulsivity, poor redirectability, irritability with safety reminders, and a preference for walking outside, but did not include interventions related to wandering or elopement despite these behaviors and diagnoses. The resident’s MDS showed a BIMS score of 13, indicating cognitive awareness, and documented that the resident required supervision or touching assistance with all mobility and assistance with several ADLs. The resident had a wander/elopement alarm noted on the MDS, but the facility’s Audit of Wanderguards did not list the resident as having a Wanderguard. Progress notes showed that an elopement risk assessment was completed and the resident was deemed to have no active elopement attempts, and the Wanderguard safety device was documented as no longer applicable. Later, the resident left the facility multiple times without signing out or notifying staff, including two exits on the same day without using the sign-out book, and continued to exit seek after being educated on sign-out procedures. On one occasion, staff became aware the resident was missing only after finding the resident’s wheelchair outside near the drive-up area, and documentation showed that staff and law enforcement had to search the surrounding area before the resident was returned by police and the Administrator. The facility also failed to implement and update fall interventions for this resident despite multiple falls. Progress notes and fall data collection forms documented falls on several dates, including in-facility falls and an out-of-facility fall, but the resident’s care plan did not show fall interventions to prevent recurrence of the falls on those dates. Root cause documentation for some falls noted factors such as spilled pop on the floor and nighttime medications causing drowsiness, but there were no documented interventions to prevent similar events in the future or after the resident returned from the hospital. Observations of the resident’s room showed paper towels scattered on the floor, multiple boxes and cases of soda and other items on the floor near the bedside table and between the bed and restroom, and the resident’s urinal hanging on a trash can by the door and not within reach. No fall interventions were observed in the room. Facility staff, including the Clinical Consultant, confirmed that interventions were not put in place following the resident’s falls and that no interventions were implemented to protect the resident from eloping because the resident was considered cognitively aware and able to make their own decisions.
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