Failure to Prevent and Report Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent a cognitively impaired resident, assessed as an elopement risk, from exiting the building and entering the parking lot without staff awareness. The resident had an MDS admission assessment showing moderately impaired cognition with delusions and wandering behaviors, and a subsequent MDS showing severely impaired cognition with continued delusions and wandering. A quarterly wandering/elopement assessment documented multiple “yes” responses to risk questions, which per the tool’s instructions required placement on wandering/elopement precautions. Despite this, the resident was observed by surveyors attempting to open the front door, repeatedly pushing on the door latch until a staff member intervened. Staff interviews revealed that the resident had previously exited the facility without staff initially knowing, and was later found outside near the front parking lot. Multiple CNAs and LPNs acknowledged awareness of at least one prior incident in which the resident was outside the building, but none could recall the exact date, and the involved LPNs and CNA stated they did not report the incident to administration. The DON stated they only became aware of the prior exit when informed by the surveyor and indicated that staff were supposed to report such incidents, but this had not occurred. There were conflicting accounts between the DON and CNAs regarding whether a particular CNA had maintained visual contact with the resident during the incident, with several CNAs stating that CNA was not present when the resident was found outside.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.