Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, resulting in an elopement incident. The resident, who was admitted to a locked unit, was moderately impaired with a BIMS score of 10 and had a history of brain surgery and mood disorder. Despite these conditions, the facility did not complete an elopement risk assessment upon admission, nor did they reassess the resident when he displayed exit-seeking behaviors, such as expressing a desire to leave and being irate about his situation. The resident's care plan was not updated to reflect his elopement risk, and staff failed to monitor him adequately. On the day of the elopement, the resident was allowed to leave the unit unsupervised to smoke, despite being on a locked unit. Staff interviews revealed confusion about the resident's privileges and lack of clear communication regarding his supervision needs. The resident was able to leave the facility and was later found at a friend's house in another city. The facility's failure to complete necessary assessments and provide appropriate supervision led to the resident's elopement, creating an immediate jeopardy situation. Staff were not adequately informed or trained on how to handle residents with exit-seeking behaviors, contributing to the oversight that allowed the resident to leave the facility without proper authorization or supervision.
Plan Of Correction
1. The facility submitted an immediate corrective action plan to on-site surveyors on 2/11/2025. 2. All residents in the facility had updated elopement assessments completed on 2/11/2025. New admissions to the facility are being audited daily to ensure elopement risk assessment is completed on admission. Facility policy on elopements was revised on 2/11/2025 to clarify what classifies a resident as being at risk for elopement. The elopement binder at the reception desk was updated. 3. Staff in all departments were re-inserviced on completion of elopement assessments and identifying exit-seeking behaviors by the nursing administration team. The facility has contracted with Core Tactics to conduct on-site directed in-servicing to all staff on 3/11/2025-3/12/2025 on recognizing elopement risks. 4. The Director of Nursing or designee will complete a 30-day audit of all new admissions started on 2/12/2025 to ensure elopement risk assessments are complete and residents who are at risk for elopement have care plan interventions in place to minimize the risk of successful elopement. Audit findings will be shared with the QAPI committee.
Removal Plan
- The facility made contact with R456 and family who returned to the facility and signed out of the facility Against Medical Advice. Facility will reassess all residents for elopement risk. Assessments will be confirmed completed.
- All residents assessed to be at risk of elopement will have care plan and interventions implemented to reduce the risk of successful elopement. Residents being housed on east side locked units who are not identified as needing a locked unit will have a physician order permitting them to leave unit unsupervised.
- Administrator and Director of Nursing will review facility elopement policy and revise as necessary.
- All facility staff will be re-in serviced on elopement policy and identifying exit seeking behaviors upon arrival for next scheduled shift. Any staff not scheduled to work will be contacted by telephone to receive education.
- Director of nursing will audit all new admissions to ensure elopement risk assessment is complete and newly admitted residents who are at risk for elopement have care plan interventions in place to reduce the risk of successful elopement.
- Policy revision, staff education and ongoing audits will be shared QAPI committee.