Failure to Supervise, Reassess Elopement Risk, and Report an Unwitnessed Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and to reassess and manage elopement risk for a resident who repeatedly expressed a desire to leave and return to the river. The resident was admitted with multiple medical diagnoses, including a wedge compression fracture of the lumbar spine, obstructive and reflux uropathy, heart disease, acute kidney failure, urinary retention, urinary tract infection, and a history of homelessness. A Minimum Data Set assessment dated 1/17/26 documented a BIMS score of 8, indicating moderate cognitive impairment. An elopement risk assessment completed on 1/12/26 indicated the resident was not considered at risk for elopement, and there was no documentation that this assessment was revisited despite the resident’s ongoing verbalizations about wanting to leave the facility. On 2/8/26, nursing documentation showed that the resident was last seen at approximately 2:15 p.m. during initial rounds and was reported missing by a CNA at about 3:15 p.m. Staff then searched the entire building, perimeter, outside areas, and surrounding buildings but were unable to locate the resident. The nurse notified the DON and Administrator at 3:40 p.m. and contacted the police at 3:48 p.m. The police later arrived to complete a report regarding the resident’s elopement. Interviews with the DSD and DON confirmed that nursing documentation initially identified the event as an elopement and that no staff member witnessed the resident leaving the facility. The DSD also confirmed there was no documentation of interventions or safety precautions, such as frequent checks or a specific care plan, implemented after the resident verbally expressed a desire to leave. The facility did not report the elopement to the State Survey Agency as required by its own policies. The Administrator, DSD, and DON acknowledged that the resident left the premises without staff awareness or supervision and that the resident had a BIMS score of 8 and a history of homelessness. After the resident’s departure, the IDT reviewed staff interviews and the physician’s H&P, determined the resident was A&Ox3, and reclassified the incident as an AMA discharge rather than an elopement. The Administrator confirmed that, based on this post-incident determination, the facility did not notify the State Survey Agency, despite the facility’s elopement policy requiring appropriate reporting to the State Survey Agency when a resident leaves without authorization and/or necessary supervision. At the time of the Administrator’s interview, the resident had still not been located.
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