Failure to Implement Elopement Protocol for At-Risk Resident
Penalty
Summary
The facility failed to implement its elopement protocol for a resident assessed at moderate risk for elopement, resulting in the resident being missing for an extended period before the protocol was initiated. The facility’s policy defined a suspected elopement as when a resident’s whereabouts are not immediately known and required staff to alert personnel using an internal alert code. The resident had diagnoses including COPD, depression, chronic pain, and polysubstance abuse disorder, and a comprehensive assessment showed the resident required supervision or touching assistance with walking and had intact cognition. An elopement risk assessment documented a moderate elopement risk score of five, but the resident’s care plan did not include an elopement care plan. The visitor sign-in sheet showed a family member visited the resident and signed in late in the morning, with no sign-out time for either the family member or the resident. On the day of the incident, an LPN administered the resident’s morning medications early in the day and later returned to give scheduled afternoon medications, at which time the resident was not in the room. The roommate reported the resident had gone to lunch with a family member, but the LPN did not call the family to verify this information, was unaware of any required time frame to contact the resident or family about return time, and did not implement the missing resident/elopement protocol, even though the resident did not return by the end of the LPN’s shift. Progress notes documented the resident as missing the following morning when the dayshift nurse noted the resident was not present for scheduled morning medications and then contacted the family, learning the resident had been dropped off in the facility parking lot the previous afternoon. The missing resident/elopement protocol was implemented at that time, approximately 18 hours after the resident was missing from the facility, and the administrator later confirmed that nothing had been done when the resident was first missing until the next day, when the resident was subsequently found by the water about half a mile from the facility and sent to the hospital for evaluation.
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