Failure to Provide Adequate Supervision to Prevent Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident with cognitive impairment and behavioral indicators of wanting to leave. The resident had a BIMS score of 11, indicating moderate cognitive impairment, and diagnoses including Alzheimer’s disease, non-Alzheimer’s dementia, and cancer. The resident’s mood interview showed frequent feelings of being down or depressed, and the resident was receiving an antipsychotic medication. An elopement evaluation completed earlier showed a score of 0, and there was no indication in the record that this assessment was updated in response to later behaviors. On one day, multiple progress notes documented that the resident repeatedly expressed a desire and intent to leave the facility. The resident told the social services director (SSD) that they were going to leave, and the SSD informed the Ombudsman, DFS, and attempted to contact the resident’s POA and family. Subsequent notes showed the resident became angry after being told by the POA that they could not take the resident home, continued to state they were leaving, declined evening medications, and ranted about leaving and having a family member pick them up. The nurse encouraged the resident not to pull out their Foley catheter, and the DON and SSD spoke with the resident. The resident then left their room with two bags of clothing, walked toward the lobby, and stated they were going home with family. Despite these escalating statements and actions indicating intent to leave, review of the medical record showed no evidence that additional supervision was implemented after the resident voiced the desire to leave. The facility’s elopement policy required that residents at risk for elopement receive adequate supervision and that charge nurses and unit managers monitor implementation of interventions and document accordingly. The DON later reported being unsure whether the resident had a wanderguard. The resident ultimately left the facility and was later located off-site, confirming that the resident had eloped after repeatedly expressing the intention to do so without the facility having implemented additional supervision measures in response to those behaviors.
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.