Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, resulting in an elopement incident. The resident, who had a history of dementia and was moderately impaired, was found outside the building on a loading dock, having exited the facility without staff knowledge. The resident's clinical records indicated a moderate risk for elopement, yet the facility did not update care plans or implement sufficient interventions to prevent such incidents. The resident had multiple episodes of wandering and confusion, which were documented in progress notes. Despite these documented behaviors, the facility did not consistently complete elopement risk assessments or notify the resident's family and physician. The facility also failed to update care plans or implement additional safety measures to address the resident's wandering and exit-seeking behaviors. The facility's lack of response to the resident's elopement risk was further evidenced by the absence of wander guard alarms on doors and elevators that did not lock when a wander guard bracelet was detected. This oversight, combined with the failure to conduct regular elopement risk assessments and update care plans, contributed to the resident's ability to leave the facility unsupervised, creating an immediate jeopardy situation.
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) - 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? - Elopement risk assessments were completed on all residents on 4/16/2025. Any resident identified as at-risk for elopement was reviewed by the interdisciplinary team for appropriate interventions to prevent elopements. Sign-in/Sign-out sheets were initiated on 4/19/2025 to monitor all resident whereabouts on and off the nursing units. 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 Elopement - Assessment, Risk & Prevention Policy was revised to include: - Added that the Elopement Risk Assessment will be performed quarterly as part of the resident's care plan review. This is in addition to performing the assessment on admission (or readmission), for changes in the residents' condition or cognition, after an elopement attempt, upon verbalizing their desire to leave the facility, and any time a staff member feels that the resident should be reassessed. - Rounds were added on an hourly basis from 11:00 PM to 7:00 AM every night and every hour for weekend shifts. These rounds will be recorded in logbooks on every nursing unit. - Sign-in/Sign-out logs were added to every unit to update staff when the residents are off the unit for an activity, appointment, or outing. Binders are at every nursing station with at-risk resident photographs and their individualized care plans. Binders are at the front desk with at-risk resident photographs. - In the event of an elopement, a full body assessment will be included. All departments (agency and staff) were educated about elopement risks and procedures, that included recognizing elopement, completing risk assessments, care plans, supervision to prevent elopement, and the Wander Guard system. - Further education will be ongoing and will be included in the new hire curriculum and at least annually with all staff education days. An emergency QAPI meeting was held on April 22, 2025, to review elopement policies and procedures. Another QAPI meeting is scheduled for May 5, 2025, to review elopement policies and procedures and progress with implementation. - CNA meetings were held on April 22, 2025, and a Licensed Nurse meeting was held on April 23, 2025, to educate clinical staff on the changes to the Elopement Policy and to discuss concerns. A Daily Stand-Up Meeting and Policy was developed and will begin on May 1, 2025. These meetings will review the 72-hour nursing report every Monday and will review the 24-hour nursing report every other weekday. The Stand-Up Meeting will address new business and reportables, high-risk review elements, and any events to be reported to the attending physicians and/or the medical director. A binder with the Stand-Up Meeting notes will be maintained by the nurse educator. - Elopement drills will be held on at least a quarterly basis, with every shift evaluated on at least a yearly basis. An elopement drill is scheduled to be conducted on 5/02/2025. A directed In-Service on 42 CFR 483.25 Accidents/Hazard/Supervision F689 will be held on May 7, 2025, by Masters crafted in Healthcare, LLC. This In-Service will include a review of all the federal regulations cited along with a review of the accompanying guidelines and be conducted on all shifts and recorded for any staff unable to attend. All staff will also be educated on new and revised policies at this time. The staff will continue to ensure that the new policies will be followed. This will be monitored at the daily Stand-Up Meetings, and audits of the rounding logbooks. All will be reported quarterly at QAPI. 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? The Elopement Prevention Audit Tool, which includes physician orders, treatment record documentation, elopement binders, incident reports, hourly logbooks, event reporting, and physician notification is being completed by the DON or designee daily for 2 weeks starting 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. Dates of when the corrective action will be completed - May 16, 2025.
Removal Plan
- An elopement assessment will be done on every resident.
- Resident R1 now has a wander guard and is moved to the first floor where the alarms are located.
- Resident R1 has been assessed for injury and family was notified of all the events.
- Elopement care plans, which include resident specific interventions, will be done on every resident.
- Hourly rounds will be added to all night and weekend shifts.
- Wander guard placement will be checked every shift, and wander guard function will be checked daily.
- At risk residents must be supervised when out of bed by a staff member to ensure residents are safe.
- Educate all departments including agency on Elopement Risk and Assessment, Care plans, Supervision, Wander guards, How to activate wander guards and where they are located, Color light indicators.
- Elopement policy revised to add head to toe assessment (full body), elopement risk assessments will be done quarterly with care plan review, elopement binders will be on each nurse's station and front desk, to include picture and room number.
- Emergency Quality Assurance Performance Improvement (QAPI) meeting will be held with all supervisors and committee members.
- All other incidents will be reviewed at regular QAPI meetings.
- Audits will be completed.
- Daily audits will be completed by DON or designee daily for two weeks, then weekly for three weeks, then monthly for three months, and then quarterly.
- Hourly Round tool will be conducted at night and on the weekends.
- Facility called an emergency QAPI meeting, and signature sheet was provided and reviewed.