Failure to Prevent Resident Elopement
Penalty
Summary
The facility's administration failed to effectively use its resources to ensure resident safety and maintain the highest practicable physical and mental functioning of its residents. This was evidenced by the elopement of one resident, which placed eight residents identified as at risk for elopement in immediate jeopardy. The administration did not provide necessary supervision and effective safety measures to monitor the resident's whereabouts, leading to the elopement incident. The review of the administrator's job description highlighted a lack of effective oversight and failure to address identified elopement risks for at-risk residents. The Director of Nursing Services (DON) also failed to provide adequate monitoring or implement effective interventions to prevent the resident's elopement. There was insufficient coordination of staff to ensure the safety of other residents at risk for elopement. The facility's inability to implement and enforce policies to monitor the resident and address elopement risks resulted in immediate jeopardy to the health and safety of the residents. This demonstrated a systemic failure in the administration's oversight and resource allocation to ensure a safe environment for residents.
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, per IDT review of the resident's individual behaviors, patterns, and routines. Residents who have been identified as at risk for exit seeking and or elopement have been entered into the facility resident exit seeking/elopement identification binder; present at the front desk, nurses stations, and dietary department; with current photo and profile, updated. 3. The NHA and DON have been reeducated by the Regional Director of Clinical Services, RN, to the facility processes for resident safety monitoring; elopement management; includes the exit seeking/elopement identification binder and Prevention and Visitation-Visitor Badge Process. Facility staff have been reeducated by the NHA and or designee to the facility processes for Elopement management; includes the exit seeking/elopement identification binder and Prevention and Visitation-Visitor Badge Process. New staff hired will be educated to the facility processes for resident safety monitoring; elopement management and Prevention and Visitation-Visitor Badge process by the NHA and or Designee prior to working in the facility as well as directed in-service for staff. 4. The NHA and or DON has audited the facilities compliance with resident safety monitoring; elopement management and Visitation Process-Visitor Identification Badge system with no further incidence of resident incident; occurring. The NHA and or DON will review new hired staff education, prior to working in the facility, to ensure resident safety monitoring; elopement management and Prevention and Visitation-Visitor Badge process has been completed. The NHA and or DON will monitor that the Exit Seeking/elopement binder has been updated, daily, for any residents identified as exit seeking/elopement risk. Trends will be reviewed by the QAPI Committee for further follow-up as needed.