Failure in Supervision and Monitoring of Elopement Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of elopement prevention devices, resulting in an elopement incident involving a resident with a history of wandering and dementia. The resident, who also had diagnoses of schizophrenia and PTSD, was found in the parking lot by a nurse who was leaving the facility. Despite having a care plan that included interventions for elopement risk, the resident managed to exit the building through the front door. The Director of Nursing confirmed that the facility did not provide adequate supervision, which led to the resident being outside the facility for approximately two to three minutes before being assisted back inside. Additionally, the facility did not adequately monitor the elopement prevention device for another resident who had a physician's order for a Wanderguard to be worn at all times. The clinical record for this resident, who was admitted with dementia and other health issues, did not show any documentation of staff checking the placement of the Wanderguard since its application. The Director of Nursing confirmed this lapse in monitoring, indicating a failure to adhere to the prescribed safety measures for residents at risk of elopement.
Plan Of Correction
0689-R 2 was transferred to a secure facility the following day. R 2 was not seen leaving the facility by the receptionist. Elopement binder available and up to date. Facility has wander guard system but R2 would not wear the wander guard bracelet. R 2's order has been fixed so that it is now visible on the treatment record and function and placement can be signed off as being verified. All residents who are identified as at risk for elopement will have their orders checked to ensure supplemental documentation is present and placement and function can be verified and documented on each resident's treatment record. Education to be provided to licensed nurses by the Director of Nursing, or designee, on the importance of ensuring supplemental documentation is completed in Point Click Care so that placement and function can be verified on each resident's treatment record. Each resident who has been identified as at risk of elopement will be audited for the next 60 days to ensure supplemental documentation is completed in Point Click Care so that placement and function can be verified on each resident's treatment record. Results of audits will be reviewed at the month QAPI meeting for tracking and trending purposes. The facility Director of Nursing shall ensure compliance.