Failure to Adequately Supervise and Prevent Elopement of an Identified Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for one resident identified as an elopement risk. The resident was admitted with vascular dementia and had a BIMS score of 15/15, indicating intact cognition, and was independent with ambulation and most ADLs. In the weeks prior to the incident, the resident repeatedly verbalized plans to leave, including stating they would discharge the next day, calling a moving company and their church for assistance, and telling staff they would call the police. On one occasion, the resident moved quickly toward an exit when discussing discharge and had to be redirected; at that time, a wander alert device was applied, and the care plan was updated to reflect elopement risk, but the care plan did not document that a wander alert device had been applied. An elopement risk assessment subsequently scored the resident as low risk despite the multiple expressed intentions to leave. The incident under review occurred when the resident exited the building without staff knowledge by removing screws from the inside window casing that were intended to limit the window opening to 2–3 inches, allowing the window to open wide enough for the resident to climb out. The resident was later observed outside, walking on the driveway near the building by a housekeeping supervisor, who attempted unsuccessfully to coax the resident back inside while the resident repeatedly stated they were leaving and not returning. Additional staff were called, and after about 15 minutes the resident returned to the building. Staff confirmed they had not been aware the resident was out of the building. The Nursing Home Administrator stated that the resident preferred to keep their door closed at all times, making it difficult to balance privacy with increased supervision. The DON reported there was no policy for documentation for nurses and CNAs when documentation policy was requested.
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