Failure to Implement Elopement Interventions for Newly Admitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement interventions to monitor and prevent elopement for a newly admitted resident with Alzheimer’s dementia who had been identified as an elopement risk. The resident was admitted from a hospital with diagnoses including Alzheimer’s and dementia, was unable to complete a BIMs assessment, and did not recognize their own name on nursing assessment. During the night shift, the resident repeatedly left their room, required redirection, and was described by the nurse as exit seeking. The nurse reported this exit-seeking behavior to the oncoming nurse and indicated the resident might need transfer to a secured unit, and the oncoming nurse was heard telling CNAs they needed to keep an eye on the resident. Despite this, no specific elopement-prevention intervention was put in place prior to the incident. On the morning of the elopement, the resident was observed on video sitting in a hallway chair and then moving to a dayroom sofa near the smoker’s exit doors while staff, including a nurse with a medication cart and CNAs passing breakfast trays, were present in the area. A CNA last saw the resident around the time breakfast trays were finished, then went to give another resident a 15–20 minute shower. Within approximately 45 minutes, the resident was no longer on the sofa and could not be located by staff. The CNA who had last seen the resident reported they had not received any direct report from night-shift CNAs about the resident’s exit-seeking behavior and initially thought the resident was a visitor when first observed sitting in the hallway. The resident exited the building through the smoker’s patio area, which was routinely unlocked during the day for independent smokers and, at the time of the incident, did not have an alarm on the interior set of doors. Staff interviews and a resident smoker confirmed that the interior door alarms were new and had not been in place or activated when smokers went out during the day prior to the elopement. Video review showed the resident walking down the sidewalk from the employee entrance toward the front of the building, and the facility later learned the resident had followed another resident who went out to smoke. The resident was found at a nearby medical clinic and returned to the facility, where they were noted to be confused by basic questions. The root cause identified by the facility was that the resident had scored as a risk for elopement on admission, but staff did not implement an intervention to prevent the resident from leaving the facility.
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