Failure to Identify and Supervise Elopement Risk
Penalty
Summary
The facility failed to ensure adequate supervision and identification of a resident at risk for elopement, resulting in an elopement incident. The resident, who had a history of substance abuse and a cerebral infarction, was admitted to the facility and initially assessed as not being at risk for elopement. However, subsequent assessments indicated that the resident exhibited behaviors consistent with elopement risk, such as wandering and expressing a desire to leave the facility. Despite these indicators, the facility did not update the resident's care plan to address the elopement risk. On the day of the incident, the resident was observed displaying exit-seeking behavior, expressing a need to inform family members of their whereabouts, although no family contact information was available in the resident's records. The resident was last seen in the common area before being observed leaving the facility with a dietary aide during a smoke break. The facility's staff, including the medical records employee and the RN supervisor, failed to recognize the resident as a potential elopement risk, and the resident was able to leave the premises without being stopped. The facility's elopement protocol was not effectively implemented, as evidenced by the lack of a comprehensive assessment and care plan for the resident's elopement risk. The facility did not have an alarm system for the doors, and staff were not adequately trained to identify and respond to exit-seeking behaviors. The failure to identify the resident as an elopement risk and provide appropriate supervision led to the resident's unauthorized leave of absence, creating an immediate jeopardy situation.
Plan Of Correction
1. Resident R1 is no longer a resident at the facility but was located post elopement by the housing director of the YMCA where the resident had lived prior to hospitalization. Resident is safe according to his friends in the northside area where he has been a lifelong resident. This was verified by the Administrator on 12 March 2025. 2. All residents will be assessed for elopement risk by the Director of Nursing or designee by the end of the day on 13 March 2025. All care plans for residents identified with elopement risks will be reviewed and updated with interventions to prevent elopement by the end of the day on 13 March 2025 by the Director of Nursing or designee. Residents admitted within the last 30 days and who are currently in-house will be added to the Elopement Binder by the Administrator or designee by 13 March 2025. 3. The elopement assessment tool will be updated by the Director of Nursing or designee by 13 March 2025. Education will be completed by all staff on Elopement Risks, Assessments, Care Plans, and Supervision of Residents by the Director of Nursing or designee by 13 March 2025. Policies and/or procedures will be updated to identify residents who are at risk for eloping by the Administrator or designee by 13 March 2025. Elopement Books with identified resident photos will be placed on all nurses stations in addition to the current one at the receptionist's desk by the Administrator or designee by 13 March 2025. A new process will be implemented by the Administrator or designee to ensure that Residents sign out of the facility when going on an LOA. This process will have the Registered Nurse (RN) Supervisor or designated nurse (RN or LPN) complete an LOA Approval Form which is to be given to the Receptionist before the receptionist can allow the resident to exit the facility by 13 March 2025. The Directed Inservice for F-689, entitled Accident Prevention and Supervision will be conducted by Affinity Health Services on April 4, 2025. 4. Audits will be implemented by the Nursing Home Administrator or designee for LOA Sign Out compliance weekly for 3 weeks and then monthly for 2 months. Audits will be implemented weekly for 3 weeks and then monthly for 2 months to monitor that the elopement assessments have been completed at admission, quarterly, and with changes in conditions. An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator or designee by the 13 March 2025. This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. 5. How the corrective actions(s) will be monitored to ensure the practice will not recur: - Audits will be implemented by 3/13/25, for LOA sign out compliance weekly for 4 weeks, then monthly for two months. - An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the NHA or designee by 3/13/25. - This plan of correction will be monitored at the QAPI meeting until such time is consistent substantial compliance has been met. On 3/13/25, at 12:43 p.m. it was confirmed 78/78 Residents were reassessed for an elopement risk. 13/78 Residents were identified as a risk, and 13/13.
Removal Plan
- All residents will be assessed for elopement risk by the Director of Nursing or designee.
- All care plans for residents identified with elopement risks will be reviewed and updated with interventions to prevent elopement by the DON or designee.
- Residents admitted within the last 30 days and who are currently in-house will be added to the Elopement Binder by the NHA or designee.
- The elopement assessment tool will be updated by the Director of Nursing or Designee.
- Education will be completed by all staff on Elopement Risks, Assessments, Care Plans, and Supervision of residents by the DON or designee.
- Policies and/or procedures will be updated to identify residents who are at risk for eloping by the NHA or designee.
- Elopement Books with identified resident photos will be placed on all nurses' stations in addition to the current one at the receptionist's desk by the NHA or designee.
- A new process will be implemented by the NHA or designees to ensure that residents sign out of the facility when going on a leave of absences (LOA).