Failure to Reassess Elopement Risk and Provide Adequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and timely elopement risk assessment for a resident who expressed a desire to leave the facility. The resident was admitted with diagnoses including stroke, hemiparesis, and urinary tract infection, and had a BIMS score of 11, indicating moderate cognitive impairment. A Wandering/Elopement Evaluation completed in early December documented that the resident was not at risk for elopement at that time. Facility policy on Elopement Prevention required that upon a significant change in condition, each resident be reassessed for elopement risk using the Elopement Risk Tool and that appropriate interventions be implemented as indicated. On a later date, a neuropsychology note documented that the resident was observed walking unassisted into the dayroom, looking toward an emergency exit door, and attempting to convince staff to allow them to leave. The note also documented increased suspiciousness and disorientation, including the resident stating an incorrect date, and indicated that nursing was aware of the mental status change and the need for continued observation. However, there was no documented evidence that an elopement risk reassessment was completed after this change or that enhanced supervision or elopement interventions were implemented that day. Video surveillance later showed the resident exiting an exterior door unaccompanied and undetected and being brought back into the building by staff approximately 35 minutes later. A nursing progress note recorded that the resident was found outside the building sitting on the curb with no apparent distress and was safely returned to the unit.
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