Failure to Complete Timely Elopement Risk Assessment on Newly Admitted Resident
Penalty
Summary
The facility failed to ensure timely completion of a Nursing Admission Data Collection, including an elopement risk assessment, for one resident, resulting in noncompliance with its elopement policy. The facility’s written policy on Elopement, Risk Reduction Strategies and Management of Missing Resident, revised 01/2024, required nursing staff to complete an elopement risk data collection on all residents at admission or no later than eight hours after admission. An admission record showed that Resident #1 was admitted at 11:14 a.m. with a medical diagnosis of vascular dementia. A nursing note documented that on the day of admission, the resident was found by police outside the facility down the road, having eloped within 4.5 hours of admission. The Nursing Admission Data Collection, which included the elopement risk data collection, was not signed as completed until five days after admission, after the elopement had already occurred. In an interview, the admission nurse confirmed that the assessment was not completed within eight hours of admission and attributed the delay to being off for the holiday. The administrator reported that 71 residents resided in the facility at the time of the survey, and Resident #1 was the only sampled resident reviewed for elopement. The record review and staff interview confirmed that the required elopement risk assessment was not performed within the policy’s specified timeframe for this resident with vascular dementia, and that the resident left the facility unsupervised and was located by police down the road on the same day as admission.
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