Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
Greenery Center for Rehab and Nursing was found to be non-compliant with federal and state regulations due to a failure in providing adequate supervision to residents at risk of elopement. The facility's policy on 'Wandering and Elopements' was not effectively implemented, leading to an incident where a resident with severe cognitive impairment and a history of wandering exited the facility unsupervised. This resident, who had been admitted with diagnoses including dementia and anxiety disorder, was identified as high risk for elopement but was not adequately monitored, resulting in her being found outside the facility in cold weather conditions. The deficiency was further compounded by the removal of the resident's Wanderguard, an electronic monitoring bracelet, shortly after it was initially placed. The decision to remove the Wanderguard was made by the Director of Nursing, who instructed the LPN to do so based on the resident not exhibiting exit-seeking behaviors at that time. However, documentation did not reflect any ongoing monitoring interventions, and the resident subsequently eloped from the facility. The incident highlighted a lack of consistent supervision and monitoring, particularly during times when the front desk was unstaffed. Additionally, the facility failed to maintain an accurate and complete 'Elopement Book' at the front desk, which should have contained information and photographs of all residents at risk for elopement. Several residents identified as at risk did not have their information properly documented, and the facility's door alarm system was found to be ineffective, as the doors could be pushed open despite the alarm sounding. These lapses in protocol and supervision contributed to the immediate jeopardy situation identified by the surveyors.
Plan Of Correction
Resident R1 has discharged from the facility on 1/22/2025. Residents with current orders for a wander guard will have been reevaluated/assessed and their care plans have been updated to reflect the most up to date information regarding their risk for elopement. The DON or Designee began education with nursing staff, including contracted staff, on the facility elopement management policy, where to locate the elopement binder and how to identify exit seeking behaviors. The DON or Designee will educate new nursing staff to the facility prior to the start of their first shift. The NHA or Designee began immediately educating dietary, housekeeping, management, laundry, and other staff on the elopement policy and where to locate the elopement binders. The NHA and or designee will educate new facility staff prior to the start of their first shift. Automated Entry Systems did an assessment of the doors on 1/28/2025 and are working to find a compatible part to lock the doors to prevent residents at risk of elopement from getting out of the front doors. The maintenance director is working with Life Safety as well to ensure the plan for the doors adheres to Life Safety Code. The DON or Designee will audit elopement assessments upon admission to review and develop appropriate interventions with the interdisciplinary team in the clinical morning meeting. The DON or designee will audit two residents weekly to identify those at risk for elopement for four weeks. Staff will attend Directed In-Services with AAE Consulting Services, Inc on 2/13/2025. Staff that do not attend the training in person on this date will have to watch the training provided prior to the start of their next shift. Until the facility can determine that the doors adhere to Life Safety Code, a staff member will remain to be assigned to monitor the doors 24/7 until the doors are adjusted for safety of residents. The NHA was notified the MD of the IJ on 1/28/2025. Findings will be submitted to QAPI for review and further action if needed.
Removal Plan
- Elopement reassessments of all residents currently identified as elopement risk.
- Complete whole house education with all staff on elopement policy/procedure, the elopement binder, and appropriate supervision.
- The door vendor was onsite to evaluate doors for repairs.
- All residents upon admission will be evaluated for elopement risk and interventions. The DON will audit two residents weekly for appropriate interventions.