Failure to Notify Physician of Resident Elopements
Penalty
Summary
The facility failed to comply with the requirement to notify a physician of elopements for a resident, identified as Resident R1, who was involved in multiple incidents of wandering and elopement. The facility's policy mandates that a physician and responsible party must be notified of any accident or incident within twelve hours. However, the facility did not adhere to this policy for Resident R1, who was found in various locations outside of her designated area on several occasions. These incidents included being found on the ground level near the kitchen, in a closet downstairs, and at the reception desk by the front door, among others. Despite these occurrences, the facility did not notify the physician as required. Resident R1, who was admitted to the facility with diagnoses including high blood pressure, dementia, and cerebral infarction, was identified as being at high risk for elopement. The resident's clinical records and interviews with facility staff confirmed the lack of physician notification for these incidents. The facility's failure to notify the physician was acknowledged by the Nursing Home Administrator and Director of Nursing during an interview, confirming the deficiency in meeting the regulatory requirements for quality of care.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? - Resident R1 now has a Wander Guard and was moved to the first floor where the Wander Guard alarms are located. Resident R1 was assessed for injury and family was notified on 4/16/2025. The physician was notified of the elopement on 4/05/2025 at 16:30. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - On 5/01/2025 an audit was completed on the nursing notes for all residents over the past 30 days. Only Resident R1 is exit-seeking and verbalizing desire to leave. This occurs almost every day. On the night shift there will always be a staff person to monitor her whereabouts. - All nursing staff were educated on the facility policy including physician notification with elopement events on 4/15/2025 and 4/16/2025. 3. What Measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? - The facility Elopement Assessment, Risk and Prevention Policy includes notifying the attending physician with any elopement incidents and was reviewed by the Quality Assurance Team on 4/16/2025. - The Change in Condition Policy has been updated to include elopement incidents and attending physician notification. Nursing staff were educated on recognizing elopement and physician notification following any elopement incidents on 4/15/2025 and 4/16/2025. 4. How will the corrective action be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? - An Elopement Prevention Audit Tool, which includes physician notification, is being completed by the DON or designee daily for 2 weeks beginning on 4/16/2025, then weekly for 3 weeks, then monthly for 3 months, and then quarterly thereafter with the results reported to the Quality Assurance Committee for further follow-up. 5. Date of when the Corrective Action will be completed - May 16, 2025.