Failure to Provide Supervision and Wanderguard Results in Resident Elopement and Death
Penalty
Summary
A deficiency occurred when the facility failed to provide required one-on-one supervision and did not apply a wander guard for a newly admitted resident with dementia and a history of elopement. The resident, who had recently been released from jail and was on parole, was admitted with diagnoses including dementia with agitation and a major cognitive disorder. Documentation from the hospital and admission records indicated the need for a wander guard to prevent the resident from leaving the facility unassisted, and active orders were in place for its application and monitoring every shift. Despite these orders, the wander guard was not available at the time of admission, and the facility did not provide documented evidence that one-on-one supervision was implemented as required. Nursing notes indicated that the wander guard was not applied, and interviews with the DON revealed that no staff member was assigned to monitor the resident at the time he left the facility. The elopement risk assessment for the resident was completed only after the resident had already eloped, and it incorrectly indicated that the resident was not at risk for elopement or wandering. The resident was last seen in the facility in the morning and was later found to be missing. Police were notified, and the resident was subsequently found deceased at a bus stop several miles from the facility. The facility's policies required supervision based on assessed needs and completion of elopement risk assessments upon admission, but these procedures were not followed for this resident, resulting in the resident's elopement and death.
Removal Plan
- The DON provided a 1:1 in service to RN regarding 1:1 monitoring intervention to ensure it is followed.
- The DON/ADON provided in service to the nursing staff regarding 1:1 monitoring intervention to ensure it is followed.
- Ensure all new admissions have a completed elopement risk assessment.
- The NHA/CEO conducted an inspection of current residents with wander guard to check for placement and function.
- The NHA/CEO provided in service training to Maintenance Staff regarding wander guard alarm.
- Return demonstration of Maintenance by Nursing Home Administrator/CEO was conducted and performed well.
- Licensed Nursing staff along with the Maintenance, checked all residents with wander guard with the alarm door, all functioning well.
- Wander guard will be checked by the licensed nurses for placement attached to the resident every shift and for wander guard to be functioning daily.
- The licensed nurses re-evaluated the Wander/Elopement Risk of the residents at high risk for Wandering/Elopement.
- Licensed Nurses will conduct visual check of high-risk resident for wandering/elopement every 2 hours indicating location of the resident.
- A designated RN conducted inspection of current residents on 1:1 monitoring to ensure proper implementation.
- Resident started on 1:1 monitoring every hour by assigned CNA to determine resident's activity and provide supervision.
- RN Supervisor conducting actual physical head count of residents during shift to shift endorsements.
- RN Supervisor prints the facility census indicating resident's name, room number and bed assignment.
- Outgoing RN Supervisor together with the incoming RN Supervisor will conduct actual physical head count during room rounds.
- Both RN Supervisors will confirm number of actual physical head count by writing the final count in the census print out. Both RNs will sign to confirm actual head count.
- Completed census with actual head count will be filed in the RN Supervisor binder.