Failure to Care Plan for High Elopement Risk Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized, comprehensive care plan addressing elopement risk for a newly admitted resident who had been clearly identified as high risk for elopement. The resident was admitted with diagnoses including dementia with behavioral disturbance, depression, and psychoactive substance abuse, and preadmission information from a general acute care hospital documented severe dementia, lack of decision-making capacity, failure to thrive, significant weight loss, and psychostimulant use disorder. An elopement risk assessment completed at admission scored the resident at 24, which the facility defined as high risk (17 or higher), and the facility’s policies required that such findings be incorporated into a baseline and comprehensive care plan with measurable objectives and interventions, including care plan interventions for wandering/exit-seeking behavior. Despite this high-risk assessment and the facility’s written policies, no elopement risk care plan was developed for the resident, and the physician was not notified to obtain an order for a wander guard. Nursing documentation and visual hourly check logs from the evening and night of admission showed multiple episodes of exit-seeking behavior: the resident attempted to exit the building several times in the west hallway and was redirected back to the room at 7 p.m., 9 p.m., and 1 a.m. A nursing progress note 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. CNA interview confirmed that exit-seeking behavior began after dinner, that the resident became upset when redirected back to his room, and that the resident was last observed asleep around 1 a.m. By 4 a.m., staff discovered the resident was no longer in the room or anywhere in the facility, and the resident’s whereabouts were unknown for an extended period. The resident’s family member reported having previously asked during a facility tour whether residents could get out and was told there was someone at the door during the day and that the door was locked and alarmed at night. The family member stated that on admission day, the resident had repeatedly asked to go home and needed reminders to stay. The family member later received notification from the facility that the resident was missing and subsequently from police that the resident had been located in another city with bruises and scratches, and the resident reported having fallen. Facility leadership and the RN supervisor acknowledged in interviews that the resident had been assessed as a high elopement risk, that the physician was not informed, and that an elopement care plan and related interventions were not initiated as required by facility policy, which could have prevented the resident from leaving the facility without staff knowledge.
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