Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and interventions to prevent an identified elopement-risk resident from leaving the building unsupervised. The resident had diagnoses including dementia, type 2 diabetes, hypertension, anxiety, major depressive disorder, and neurocognitive disorder with Lewy bodies. A Significant Change MDS showed a BIMS score of 03, indicating severe cognitive impairment. The resident used a wheelchair and required moderate assistance for transfers and mobility. An elopement assessment completed earlier in the year scored the resident as high risk for elopement, and the care plan identified the resident as an elopement risk/wanderer with a history of attempts to leave the facility unattended and impaired safety awareness. The care plan for this resident included goals to maintain safety and interventions such as distracting the resident from wandering with diversions and structured activities, identifying patterns of wandering and diverting as needed, initiating 1:1 supervision if the resident exhibited exit-seeking or verbalized wanting to leave, monitoring for fatigue and weight loss, providing activities of interest to deter wandering, and providing supervision for off-unit activities. Despite these identified risks and planned interventions, on the day of the incident the resident was able to leave the building without staff awareness. The resident’s wheelchair remained inside the facility, and staff later reported they were unsure how the resident had the strength to open the doors and ambulate outside, as they had rarely seen the resident walk and knew the resident required assistance for mobility. The event came to light when another resident, while watching TV, noticed a man sitting on a parking stop in the parking lot in the rain and realized it was a resident. This resident activated the call light and informed a CNA that there was a resident outside. Staff then observed the elopement-risk resident sitting outside in the rain in the parking lot and assisted him back into the building. Multiple CNAs and the administrator confirmed that staff only became aware the resident had left the building after being alerted by another resident. The facility’s written policy on unsafe wandering and elopement stated that staff will identify residents at risk, assess for risk factors, care plan for elopement risk with safety interventions such as monitoring plans and devices, and treat a missing resident as a facility-wide emergency with initiation of an elopement/missing resident procedure; however, the resident was able to exit and remain outside unsupervised until discovered by another resident.
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