Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to a resident who did not have a leave of absence (LOA) order, resulting in the resident exiting the third floor via elevator and walking out the front entrance of the facility. The resident was located two hours later, approximately 1.2 miles away from the facility in a busy urban area. This incident was identified as an Immediate Jeopardy past non-compliance, placing the resident at high risk for injury. The resident, who was admitted with a history of repeated falls, difficulty walking, fracture of the pelvic bone, and cognitive communication deficit, had a BIMS score indicating moderate cognitive impairment. The resident's care plan required one-person staff assistance for ambulation, and there was no documented evidence of a physician order for a leave of absence. Despite this, the resident managed to leave the facility without staff intervention, as the receptionist mistook the resident for a visitor and allowed them to exit. The facility's policies on wandering and elopements, as well as resident leaves of absence, were not followed. The receptionist, distracted by personal activities on the computer, failed to recognize the resident and did not adhere to the protocol of ensuring visitors and residents sign out and wear visitor badges. This oversight, combined with the lack of supervision and failure to identify the resident's risk of elopement, led to the resident's unsupervised departure from the facility.
Removal Plan
- Resident left the Center to take a walk. The resident had walked to her previous address and was visiting neighbors. The Center staff spoke with her friend, and she was assisted back to the Center. Upon return, RN Supervisor assessed, and no injuries were noted.
- The Center completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for and resting comfortably.
- The Nursing Administration held huddles on all floors with staff on duty to discuss the current residents which go on frequent LOAs as well as the signs and symptoms that may indicate the risk for leaving the Center without staff notification. No variances were noted, and no current residents were identified as an elopement risk.
- Shift RN Supervisor provided immediate education to receptionist on duty.
- RN Supervisors were educated on the completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee.
- Staff were educated on signs and symptoms that may indicate a risk of elopement. 100% completion.
- Reception/security staff were educated on the process of each visitor receiving a badge that must be returned prior to door being opened and visitor leaving the premise. 100% completion.
- Staff educated on elopement/missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premises and the surrounding areas, notification processes including local police department. 100% completed.
- Staff educated on elopement drills including how often and expected response. 100% completion.
- All the training above will be added to our general orientation schedule for all new future employees.
- Residents with a current unsupervised LOA order were re-educated on the LOA policy/agreement and understood the sign out process with both the nursing staff on the unit.
- Auditing census compared to headcount every 4 HRS (hours) for 3 days then every shift for 14 days then daily. All variances will be reported to the QAPI (Quality Assurance Improvement Program) Committee monthly.
- Random audit of five visitors to ensure compliance with the visitor pass system two times daily for 14 days then daily for two months. All variances will be reported to the QAPI Committee monthly.
- Daily audit of LOA log to ensure reception/security staff are checking for clearance to leave the Center. The audit will be completed daily for three weeks with all variances reported during the clinical meeting.
- The QAPI Committee will make recommendations to ensure continued compliance. Upon sustained compliance, the QAPI Committee will recommend the reduction or resolution of the audits.