Failure to Identify Elopement Risk and Provide Adequate Supervision Leading to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to identify and supervise a resident at risk for elopement, resulting in the resident leaving the building unsupervised. The resident was admitted from the hospital with a diagnosis of schizophrenia, was cognitively intact with a BIMS score of 15/15, ambulatory without assistive devices, and required supervision with ADLs and mobility. On the day of admission, a social worker documented that the resident repeatedly stated she did not want to be in the facility and refused a mental status exam, but was able to state the correct date. Despite this, the resident’s elopement assessment later documented that the resident did not verbalize a strong desire to leave, and the care plan stated that the resident voiced no interest in community re-entry. On the night of the elopement, nursing staff documented that the resident had been lying quietly in bed during rounds before a stairwell alarm sounded. Staff responded to the alarm, and a CNA went to the third-floor stairwell door, entered the code to silence the alarm, and did not see anyone in the stairwell. Shortly afterward, another alarm sounded from the first floor. The CNA went to the first floor and observed the resident standing near an outside exit door. The resident remained at the door for about two minutes and then pushed through the exit door. The CNA followed the resident outside and stayed approximately 5–6 feet away, observing that the resident was calm and staying in place initially. The CNA then left the resident outside to re-enter the facility to obtain his coat, hat, and phone because of the cold weather, leaving the resident unsupervised. When he returned less than two minutes later, the resident was no longer in the area. Staff searched around the building and checked exit doors but were unable to locate the resident. Police were called, and the resident was later found offsite and taken to the hospital after stating she might have frostbite and requesting to go to the hospital. The Social Services Director later stated that residents are considered at risk for elopement if they verbalize wanting to leave the facility and that, had she been informed of the resident’s statements about not wanting to be there, the elopement assessment should have reflected that and the team would have addressed it. She also stated that the social worker who documented the resident’s desire not to be in the facility did not inform her of this information.
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.