Failure to Supervise and Identify Resident Leads to Unsupervised Exit
Penalty
Summary
A cognitively impaired resident, recently admitted to a secured facility, was able to exit the building unsupervised after a restorative nurse aide (RNA) opened a locked gate without verifying the individual's identity. The RNA mistakenly believed the resident was a visitor and did not check for an identification wristband or confirm with licensed nursing staff before allowing the person to leave. Video surveillance confirmed that the resident walked through the locked gate and exited the facility without staff present in the lobby. The resident had a history of dementia, psychosis, and was considered gravely disabled, with multiple medical diagnoses including hypertension, diabetes, and a history of self-neglect. Upon admission, the resident required assistance with activities of daily living and was not provided with an identification wristband, as the facility did not utilize them at the time. Staff interviews revealed that there was no policy or procedure in place for verifying the identity of individuals leaving through the locked gate, nor was there a system for monitoring the gate or ensuring residents wore identification wristbands. The incident was discovered when staff were unable to locate the resident, prompting a search and notification of local authorities. The facility's policies on wandering, elopement, and supervision referenced general safety measures but did not address specific procedures for resident identification or monitoring of secure exits. Staff involved acknowledged that the failure to verify identity and lack of a monitoring system contributed directly to the resident's unsupervised exit from the facility.
Plan Of Correction
Immediate Corrective Action: On 04/24/2025, the facility, under Administrator and Director of Nurses instruction, initiated the missing resident protocol. The staff called local hospitals. The facility searched facility premises and close surroundings. Local Law enforcement was called for support. MD was informed. Resident's representative was informed. The facility continued search on 04/25/2025. On 4/25/2025 at around 5:00 pm, Resident 1 was located and found in her apartment approximately 7.8 miles away from the facility, by RN 1 and LVN 1 and 2, with support from local police officers. On 4/25/2025 at around 5:56 pm, Resident 1 returned to the facility accompanied by RN 1, LVN 1 and 2, and local police officers. Resident 1's vital signs were checked by RN 2: B/P - 154/52, Temperature - 98.5, Respiration - 17, Pulse - 73 (regular), and oxygen saturation was 96% on room air. Resident 1 was alert and oriented x2. Resident denied pain and no emotional distress was noted. Resident 1's skin condition was also checked upon return by RN 2 and noted to have a scab on LT knee and discoloration on LT gluteal area, which were already identified on admission on 4/25/2025. Resident 1 ate at around 6:50 pm and consumed 100% of her meals. On 4/25/2025, Resident 1's attending physician was notified of her return at around 6:00 pm, and the known emergency contact was also notified and aware of her return at around 6:00 pm. On 4/25/2025 at around 8:30 pm, Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation. On 4/26/2025, Resident 1's blood sugar level was 186, taken at the GACH at around 11:50 pm. On 4/25/2025, RNA 1 was given a disciplinary action and was suspended by the Administrator until further notice pending investigation. This resulted in immediate termination on 04/25/2025. From 6:30 am on 4/25/2025 to 4/26/2025, the Director of Nursing, QA Nurse Consultant, and Director of Staff Development conducted a series of in-service training and re-education to staff about Safety and Supervision of Resident policy, Elopement, Missing Person, and Resident Identification policies, with emphasis on the following: - The purpose and importance of identifying and confirming with Licensed Nurse/RN Supervisor/DON or Administrator/Receptionist whether the person leaving is a visitor and not a Resident of the facility first and foremost before allowing anyone to leave the premises for safety. - The purpose and importance of keeping Residents safe and well-being, particularly in a secured setting, by supervising Residents while in the facility as needed and being mindful of their whereabouts at all times to ensure their safety. - The purpose and importance of identifying Residents by checking if they are wearing an ID wristband or have another form of identification (e.g., photographs) to help identify Residents and ensure they receive appropriate care and services. - The purpose and importance of immediate action/interventions, such as initiating a code (GREEN) to start a search immediately once a Resident is found missing. - The purpose and importance of seeking assistance from Local Police on a search. As of 4/25/2025, there are 113 employees who have received in-service training and re-education, and on 4/26/2025, an additional 10 employees received training, totaling 95% of current employees who have completed their required in-services/re-education regarding the topics mentioned above, excluding 7 employees currently on leave of absence (LOA)/vacation. This training and re-education are ongoing and will continue until all 130 active staff/employees are captured. On 05/14/2025 through 5/15/2025, re-education and training were conducted by a Licensed Psychologist. The facility has 130 current employees, of which 123 completed their required in-services, re-education, and post-test, reaching a total of 95%. Out of the 130 employees, 7 are excluded due to LOA/vacation. This training and re-education are ongoing and will continue until all staff are trained. Staff members who were unavailable to attend the in-service/training for any reason will be given an in-service before returning to work. A post-test was also provided to assess understanding and knowledge of the topics covered. Effective 4/25/2025, this in-service/training and re-education will be provided monthly for 4 months, then annually and as needed thereafter. On 4/25/2025, the Medical Director was notified of the incident, and QAPI was initiated by the Administrator to analyze and investigate the root causes of the deficient practices. On 4/26/2025, a new policy regarding the Secured Unit/Facility was reviewed with the Interdisciplinary Team (IDT) members, including but not limited to, the Administrator, Director of Nursing, Director of Staff Development. The new policy was reviewed and approved by the quality assurance meeting on 05/12/2025 and will incorporate the following guidelines: - Admission process - Environment considerations - Visitation procedures Action taken to identify all other residents: On 4/25/25, RN Supervisor/Social Service Director checked all Residents and conducted a headcount, verifying residents based on census to ensure all residents were accounted for and present in the facility, excluding residents in hospital on bed-hold. No residents were found to be affected by the deficient practice. On 4/26/2025, Licensed Nurses, the Medical Records Director, and Designee checked all residents to see if they were wearing identification wristbands. Four residents were found not to be wearing wristbands due to refusal. An IDT meeting was conducted to discuss residents' non-compliance, respecting their rights, and informing their physicians and responsible parties. Refusals to wear wristbands are addressed in the care plan. Also on 4/26/2025, the Social Service Director or Designee and Licensed Nurses evaluated all residents to ensure they felt safe and secure in the facility using a safety/wellness evaluation tool. No residents were affected by this deficiency. Process and action taken to prevent recurrence: 1. The facility will assign a staff member to monitor the reception area daily, 7 days a week, to oversee the front lobby and monitor individuals entering and exiting. The assigned receptionist will inform the Social Service Director and/or Designee five times a week (Monday-Friday), and the "Manager of the Day" on weekends, as coverage. An alarm has been installed on the main entrance door to alert staff when someone enters or exits, especially in the absence of the receptionist or staff manning the front lobby. 2. Visitors will sign in and record the date/time of the visit, reason for the visit (destination), prior to entering the facility, and will sign out when leaving. Visitors may be required to present a photo ID to verify their identity before entry. 3. Visitors will wear a visitor sticker for identification during their visit. They may be asked to show a photo ID if they refuse or lose the sticker, or if there is a need to confirm their identity against the visitor log and Resident ID system (e.g., wristband). 4. Effective 4/25/2025, the Administrator installed a buzzer at the gate to alert staff when assistance is needed at the gate area to identify individuals wanting to leave before exiting. The Administrator/Designee will check the buzzer's function randomly twice a week for three months, then monthly thereafter. If the buzzer malfunctions, Maintenance will replace it immediately. After hours, RN Supervisor will be informed for assistance. 5. Staff will use the buzzer to alert Licensed Nurse/RN Supervisor for assistance in identifying and/or assisting individuals leaving the premises, verifying with the physician if out-on-pass is permitted, and whether the Resident is leaving with an authorized person. 6. The Administrator will review the visitor's log randomly twice a week for three months, then weekly, to ensure proper sign-in/out and purpose documentation. 7. RN Supervisor/Designee will apply an ID wristband upon admission or readmission of Residents, including taking a photograph to upload into the Resident's electronic records (PCC). 8. A GREEN wristband will be provided to Residents who are ambulatory without assistance to identify them and alert staff about the risk of elopement, especially near exit doors. 9. The Administrator will schedule random room rounds five times a week (Monday-Friday) for three months, then three times a week thereafter, assigning at least three rooms per Department Head or IDT member for inspection. The "Manager of the Day" on weekends will conduct additional random room inspections, including checking if Residents are wearing wristbands. 10. Licensed Nurses will conduct visual monitoring every 30 minutes for 72 hours to check on newly admitted Residents' whereabouts, activity, and behavior. Monitoring performance to ensure correction is achieved and sustained: Findings from monitoring reports will be reviewed and presented to QA monthly for further resolution and recommendations. Any issues of non-compliance will be reviewed by the QA Committee for additional actions until no negative trends are observed and 100% compliance is maintained for three consecutive months. The Administrator and/or Director of Nursing will oversee ongoing compliance. How corrective action will be accomplished for residents affected by the deficient practice: The Administrator completed 40 CEU units for license renewal on 04/27/2025. The renewal application and payment were mailed to the CDPH Licensing Department on 04/28/2025, pending review and approval. How the facility will identify other residents at potential risk and take corrective action: All residents within the facility have the potential to be affected by the deficient practice. On 04/28/2025, the Regional Director of Operations provided an in-service to the Administrator on maintaining licensure and addressing disciplinary actions for deficiencies.
Removal Plan
- The Administrator gave a disciplinary action and suspended RNA 1 pending investigation.
- Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 1, and 2 local police officers located Resident 1 in Resident 1's apartment, approximately 7.8 miles away from the facility.
- RN 1, LVN 1, and 2 local police officers accompanied Resident 1 back to the facility. RN 2 completed Resident 1's skin assessment and noted a scab on Resident 1's left knee.
- Resident 1 was transferred to General Acute Care Hospital (GACH) 1 for further evaluation.
- The DON, the Quality Assurance (QA) Nurse Consultant, and the Director of Staff Development (DSD), conducted a series of in-services to staff regarding 'Safety and Supervision of Residents,' 'Elopement,' 'Missing Person,' and 'Resident Identification' policies, emphasizing: a) Identifying and confirming with Licensed Nurses, RNs, the Administrator, or Receptionist that the person leaving the facility is a visitor and not a resident before allowing anyone to leave the secured premises; b) Supervising residents while in the facility and always being mindful of their whereabouts; c) Identifying residents by checking for ID wristbands or another form of identification such as a photograph; d) Immediate action and interventions such as initiating a code to initiate search immediately once a resident was found missing; e) Seeking assistance from the Local Police Department in searching for a missing resident.
- LN, Medical Records Director, and Designee checked all residents to see if in-house residents were wearing ID wristbands. Four residents who refused were addressed in their care plans after an Interdisciplinary meeting.
- The Social Service Director (SSD) or designee and LNs evaluated all residents to see if the residents feel safe while in the facility using the safety/wellness evaluation tool. No other resident was found to be affected by the deficient finding.
- The IDT members comprising of the Administrator, the DON, and the DSD reviewed a new policy pertaining to secured unit/facility integrating the guidelines on admission process, environment special consideration, and visitation: a) The RN or Licensed Designee will immediately apply an ID wristband to a resident upon admission and upload a photograph in the resident's electronic health record; b) Green colored ID wristbands will be provided to residents who are ambulatory without assistance for identification and to alert staff about the risk for elopement; c) The Administrator will assign Department Heads or IDT members to conduct room inspections and check residents for ID wristbands, and assign a 'Manager of the Day (MOD)' on weekends to conduct random room inspections; d) LNs will conduct visual monitoring every 30 minutes for 72 hours to check newly admitted residents' whereabouts, activities, and behaviors; e) The facility will assign a staff member to monitor the reception area daily seven days a week, and an alarm has been installed on the main entrance door to alert staff when someone is entering or exiting in the absence of the receptionist.