Failure to Prevent Elopement and Follow Elopement Procedures for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement measures to prevent an avoidable elopement for a resident with schizoaffective disorder who was assessed as high risk for elopement and lacked decision-making capacity. The resident’s Wandering Risk Assessment identified a high elopement risk, and physician orders and admission documentation indicated the resident did not have capacity to understand choices and make decisions. The care plan documented that the resident was non-compliant with the wander management system (WMS) and was a fall risk, but it did not include nursing interventions for monitoring safety or reducing elopement risk, nor did it address the resident’s schizoaffective disorder or how related behaviors would be monitored. Progress notes documented that the resident refused the WMS and was on high elopement risk, with restlessness and agitation, but staff did not document monitoring interventions or best practices to keep the resident safe from elopement. On the date of the incident, a licensed nurse documented at 7:35 p.m. that the resident was not found in the facility, but there was no documentation that a Code Pink was announced as required by the facility’s elopement emergency procedures. The same nurse documented at 10:05 p.m. that the DON was notified the resident had left the facility, indicating an administration notification delay of more than two hours. A later progress note at 3:17 a.m. showed the DON faxed notification to the police department, exceeding the policy requirement to notify police if the resident is not located after 30 minutes. Staff interviews revealed that residents outside smoking after the main entrance doors locked at 5 p.m. needed to ring a doorbell for re-entry and that one CNA could not tell when residents left the floor if busy elsewhere and confirmed the resident did not wear a WMS and no Code Pink was heard. The DON confirmed the resident lacked capacity, was high risk for elopement, that the care plan did not address the mental illness diagnosis, and that there were no interventions for monitoring safety when the WMS was not worn. The facility’s policies required identification of residents at risk for wandering/elopement, inclusion of safety strategies in the care plan, and initiation of the elopement/missing resident emergency procedure, including announcing Code Pink, notifying administration, and notifying police if the resident was not located after 30 minutes.
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