Resident Elopement Due to Inadequate Supervision
Penalty
Summary
Lakewood Rehabilitation and Healthcare Center failed to ensure adequate supervision and safety measures for a resident identified as a wandering risk, leading to the resident's elopement. The resident, who had been admitted with Parkinson's disease and schizoaffective disorder, was known to exhibit exit-seeking behaviors and had a severe cognitive impairment with a BIMS score of 6. Despite these known risks, the facility did not effectively monitor or prevent the resident from leaving the premises unsupervised. On the night of the incident, the resident was last seen by staff at 9 P.M. and was reported missing at 1:45 A.M. The RN supervisor on duty, who was unfamiliar with the residents and the facility's wandering identification process, mistakenly allowed the resident to exit the building, believing the resident was a visitor. This lack of awareness and failure to confirm the resident's identity contributed to the resident's unsupervised departure. The resident was found 0.5 miles away at a car wash, exhibiting signs of hypothermia and injuries consistent with a fall. The facility's failure to promptly identify the resident's absence and implement effective supervisory measures placed the resident in immediate jeopardy, resulting in potential harm and necessitating emergency medical intervention.
Plan Of Correction
1. Resident # 1 no longer resides in the facility. 2. Current residents have been evaluated for exit seeking/elopement risk. Those residents identified as at risk for exit seeking and or elopement have had safety measures/interventions updated in their plan of care. 3. Facility staff have been re-educated by the NHA and or Designee to the facility processes for Elopement management and Prevention and the Visitation- Visitor Badge Process. Random audits will be completed by the NHA and or designee, weekly x 2 then monthly x 2, on residents at risk for exit seeking and or elopement. Random audits will be completed by the NHA and or designee, weekly x 2 weeks then monthly x 2, to ensure staff knowledge is maintained on the facility processes for Elopement management and Prevention and the Visitor Badge Process. Trends will be reviewed by the QAPI Committee for further follow-up as needed.
Removal Plan
- The resident was discharged from the facility from the hospital emergency room and admitted to a facility with a locked dementia unit.
- All residents were assessed for elopement/wandering.
- Staff education was completed regarding elopement/wandering/resident safety.
- The facility visitation policy reviewed and revised.
- Audits were completed to ensure that no other residents in the facility are affected.
- Implemented a process of the RN supervisor will verify that all residents are accounted for at the beginning of each shift by physically performing walking rounds in the facility each shift.
- RN Supervisor will validate that nurse aides understand assignments/assigned residents. Education to Nursing staff regarding staff assignments was completed.
- Facility completed staff education regarding elopement/wandering and visitation. Education regarding staffing, staff assignments and staffing responsibility was initiated for the 7 A.M. to 3 P.M. and 3 P.M. to 11 P.M. shifts. The 11pm-7am shift will be educated when they arrive before their scheduled shift. All nonscheduled staff will be educated prior to their next scheduled shift, and no staff will be permitted to work until they have received the education.
- Facility QAPI committee convened to review the initial interventions and start this plan. The QAPI committee to meet to complete the plan.