Failure to Prevent Elopement and Provide Adequate Supervision for Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for two residents with cognitive impairment. One resident, admitted with metabolic encephalopathy, cognitive communication deficit, and a psychotic disorder with hallucinations, had a BIMS score of 11/15 indicating moderate cognitive impairment. This resident exited the facility without staff authorization on two separate occasions. On both dates, the resident went to a nearby hospital emergency room (ER) during times such as lunch, and facility staff were unaware of the resident’s absence until contacted by hospital staff. The DON confirmed that both elopements occurred without the facility’s knowledge and that an electronic wander guard device was not implemented until after the second elopement. The second resident involved in the deficiency was admitted with unspecified dementia, cognitive communication deficit, and difficulty in walking, and had a BIMS score of 3/15 indicating severe cognitive impairment. This resident experienced an unwitnessed fall after eloping from the facility and was found by staff outside the front door at the top of a sloped walkway, sitting on the ground next to her wheelchair and crying. The resident had visible injuries, including a bluish bump to the left cheek and temporal area, a skin tear to the left elbow with moderate bleeding, and an abrasion to the left knee. A licensed nurse reported seeing the resident on the ground outside, observing the bleeding elbow and the developing facial bump. Record review of an investigation summary for the second resident’s unwitnessed fall and elopement identified that the most likely contributing factor to the elopement was the reception area near the front door being unattended for a brief period. The facility’s own policies on wandering, elopements, and fall risk management state that residents at risk for unsafe wandering or elopement should have care plan strategies and interventions to maintain safety, and that staff will identify interventions related to specific risks and causes to try to prevent falls. Despite these policies and the residents’ documented cognitive impairments and mobility issues, the residents were able to leave or be outside the facility without staff awareness or supervision, resulting in elopements and, for one resident, an unwitnessed fall with injuries.
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