F0689

D

Failure to Supervise Elopement-Risk Resident on Leave of Absence

Philadelphia, Pennsylvania Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The facility failed to provide adequate supervision and implement elopement interventions for a resident identified as being at risk for elopement. Facility policies required residents to be assessed for elopement risk upon admission, routinely, and with significant changes, and for residents identified as at risk to have individualized care plan interventions and close monitoring. The Elopement Prevention Policy also required staff to document exit-seeking behaviors, promptly report attempts to leave, and remain with the resident while notifying the charge nurse if a resident attempted to leave. The Leave of Absence (LOA) Policy required staff to ensure clinical stability, obtain a signed LOA form, document departure and return times, and complete a nursing assessment upon return, with additional steps if a resident did not return as expected.

Resident R1 was admitted with multiple diagnoses including coronary artery disease, hypertension, diabetes mellitus, CVA, malnutrition, generalized weakness, and a history of falls, and required partial to moderate assistance with transfers and ambulation, and total assistance for car transfers. An initial elopement risk evaluation at admission scored the resident at 0, but a subsequent evaluation on January 20, 2026, scored the resident at 2.0, indicating elopement risk based on a history of attempting to leave without informing staff, wandering behavior, and recent admission with incomplete adjustment to the facility. Despite this identified risk, the record did not show implementation of specific elopement-related interventions or restrictions on unsupervised departures.

Nursing notes and the LOA log showed that the resident left the facility on a LOA on February 3, 2026, and returned the same day without incident, and left again on February 4, 2026, accompanied by a brother and did not return. Social services documented that the resident left around 11:00 a.m. on February 4 and did not return as expected, and attempts to contact the resident and a prior shelter were unsuccessful. The Medical Director stated he does not write blanket LOA orders, that an order should be written each time a resident leaves, and that a resident identified as an elopement risk should not leave without staff supervision. The DON reported that LOA/day pass documentation was limited to signing out, with no requirement for formal documentation, education, or medication reconciliation, and the Social Worker stated she was unaware the resident was an elopement risk and was unfamiliar with the facility’s elopement and LOA policies. These actions and inactions resulted in the resident at known elopement risk leaving the facility and not returning, without appropriate supervision or adherence to policy requirements.