Failure to Adequately Supervise High-Risk Resident to Prevent Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent elopement for one resident identified as an elopement risk. The resident had non-Alzheimer's dementia, delirium due to a psychological condition, anxiety disorder, a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive dysfunction, and a documented history of wandering. The care plan, initiated prior to the incident, identified the resident as an elopement risk with interventions including structured activities and diversions. Despite these identified risks and care plan interventions, the resident was able to leave the facility and was later found at a nearby park approximately 50 yards from the facility's back door, on the other side of a small hill. At the time of the elopement, eight direct care staff were on duty. Following the elopement, documentation and staff interviews showed that the resident was to have one-on-one supervision with staff during waking hours, and staff described interventions such as remaining with the resident, providing snacks, treats, and fidget items, and using distraction with activities and toileting. Observations on multiple days showed the resident walking up and down the halls with a CNA, unsteady on their feet and requiring hands-on assistance, and staff attempting to redirect the resident to sit in a chair without success. The facility’s elopement prevention policy stated it was the policy to protect residents from elopement, and staff reported that only employees had the door code and that they were educated to check exit doors when near them and keep residents engaged. Despite these measures and the resident’s known elopement risk and cognitive impairment, the resident had previously been able to exit the building and reach the nearby park, demonstrating a failure to provide adequate supervision to prevent elopement.
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.