Failure to Notify Physician and Implement Elopement Precautions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its Change of Condition – SBAR policy and its Wandering/Exit Seeking Behavior policy for a newly admitted resident with severe dementia, depression, and psychoactive substance abuse. The resident had been hospitalized for failure to thrive, significant weight loss, and psychostimulant use disorder, and was documented as lacking capacity to make decisions. On admission, an elopement risk assessment scored the resident at 24, which the facility defined as high risk for elopement. Facility policy and the Registered Nurse Supervisor’s interview indicated that such abnormal findings required physician notification to obtain orders for a wander guard, but the physician was not informed and no wander guard order was obtained. On the day of admission, staff documented and observed multiple episodes of exit-seeking behavior. The visual hourly check log, initiated that afternoon, recorded that the resident attempted to exit the building several times in the evening and overnight, and that staff redirected and returned the resident to his room on at least three occasions. Nursing progress notes described the resident walking the hallway looking for an exit, expressing a desire to leave because he wanted to “live his life to the fullest,” and being difficult to redirect. Despite these repeated behaviors and the high elopement risk score, there is no documentation that the physician was notified or that elopement precautions requiring a physician order, such as a wander guard, were implemented. In the early morning hours following these events, the visual check log showed that at 4 a.m. the resident was no longer in his room. A CNA reported that the resident had been asleep around 1 a.m. and was still asleep when the CNA left for break at 3:30 a.m., but when the CNA checked again at approximately 4:20 a.m., the resident could not be found in his room or elsewhere in the facility. The resident’s family member reported having previously asked during a facility tour about residents’ ability to get out and was told there would be door monitoring and alarms. The family member later received a call from the facility stating the resident was missing, and then a call from police that the resident had been located in another city with bruises and scratches, with the resident stating he had fallen. The DON confirmed that once a resident is identified as an elopement risk, protocol including staff alerting and wander guard placement with a physician order should be initiated as soon as possible, which did not occur in this case.
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