Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent the elopement of a resident identified as being at high risk for elopement. The resident, who had diagnoses including schizophrenia, unspecified dementia, and atherosclerotic heart disease, was able to exit the facility undetected. The resident was known to have impaired cognition and was assessed as high risk for elopement, with a care plan that included enhanced monitoring for exit-seeking behavior. However, there was no documented evidence of close supervision or frequent monitoring prior to the resident's elopement. On the day of the incident, the resident was last seen in the lobby around 11:30 am, waiting for the mailman, which was part of their usual routine. The receptionist observed the resident handing mail to the mailman and then walking past the desk, but did not see the resident again. The resident was not accounted for during the afternoon, and it was not until after 5:00 pm that staff realized the resident was missing. A Code Gray was initiated, but the facility's search was unsuccessful, and the resident was later found by the Los Angeles Police Department. The facility's investigation revealed that the resident exited through the front door during a busy holiday period when the reception staff was occupied. The facility's cameras in the lobby were not functional, and there was no live feed or recordings to assist in the investigation. The facility's policy required residents at risk for elopement to be closely supervised and frequently monitored, but there was no documentation to support that this was done for the resident prior to their elopement.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 Resident #1 remains in Los Angeles. Upon return to the facility, resident will be re-evaluated for elopement risk with updated care plan and interventions. All residents with wander guards, exiting seeking behaviors, and those spending excessive time off the unit in the lobby or recreation room have the potential to be affected. All residents with wander guards, high risk for elopement, exit seeking behaviors, and those who spend excessive time off units were re-evaluated for elopement risk, and audits and chart reviews completed. Elopement Binders, Care plans, and interventions were updated accordingly. The facility policy on Elopement Prevention was reviewed by the Administrator and Director of Nursing and determined to be in compliance with state and federal guidelines. No revision made. Staff Educator/designee will educate all staff on facility policy on Elopement Prevention with a focus on closely supervising residents high risk for elopement. Unit sign-in/out sheets at nursing stations were implemented to account for residents being taken on or off the unit by rehab, recreation, etc. Staff rounding tool was implemented to account for unit residents during the shift, indicating resident location. Residents identified as high risk for elopement and are non-compliant with wander guard will receive enhanced monitoring/supervision every 1-3 hours. Staff Educator/Designee will in-service all staff on implemented procedures and forms. Front desk staff re-educated on emergency codes, monitoring of lobby, elopement policy, and awareness of door alarms. Facility elopement drills will be conducted weekly for 4 weeks and then monthly. The audit results will be submitted to the monthly QAPI meeting for review and recommendations. The Responsible Party: Assistant Administrator.