F0689

J

Failure to Supervise Resident at Risk for Elopement Resulting in Death

Salinas, California Survey Completed on 04-09-2025

Penalty

No penalty information released

Summary

A deficiency occurred when the facility failed to provide adequate supervision for a resident who was at risk for elopement. The resident, who had a history of walking independently with a front wheel walker and required supervision or touching assistance for ambulation, left the facility premises without staff knowledge. The resident had previously demonstrated exit-seeking behavior, including being observed walking toward the parking lot and expressing a desire to go outside, as well as leaving the facility to visit his old apartment without informing staff. Despite these incidents, there was no documented elopement risk assessment, care plan, or interdisciplinary team (IDT) note addressing the resident's behavior or risk for elopement.

On the day of the incident, the resident was last seen in his room in the morning, but staff did not notice his absence until several hours later. The resident's walker was found by reception, but he was not in the building. Staff initiated a search after realizing the resident was missing, and a Code Orange was called. The facility was later informed that the resident had been found unresponsive at a nearby bus stop by a bystander, who called emergency services. The resident was resuscitated and transported to an acute care hospital, where he subsequently died.

The facility's records revealed multiple missed opportunities to identify and address the resident's risk for elopement. There was no SBAR communication, elopement evaluation, or care plan initiated after previous incidents of the resident leaving the facility or expressing a desire to do so. Staff interviews indicated a lack of understanding regarding when to conduct elopement assessments and what constitutes an elopement. The facility's policy defined elopement as leaving the premises without authorization or necessary supervision, but this was not consistently applied in practice.

Removal Plan

• The ADM, DON and ADON initiated in-service for staff (Licensed Nurses, Certified Nursing Assistants, dietary, housekeeping and laundry, rehabilitation department, admissions, activities and maintenance) on how to locate missing residents and what is considered elopement.
• The facility's Interdisciplinary Team (IDT) completed a facility-wide audit to evaluate 65 residents for the risk for elopement.
• 13 residents at risk for elopement were monitored by Licensed Nurses for episodes of exit seeking behavior every shift and documented in the Medication Administration Record (MAR).
• LVN, RN, CNA and staff from other departments who did not attend the in-service will be provided education at the beginning of their next scheduled shift by the DON, DSD or ADON.
• The facility's ADON initiated an in-service to LVN and RN on the policy and procedures titled Elopements Resident Behavior and Facility Practice, including how to locate a missing resident, completion of elopement assessment for new admissions and residents who exhibit wandering behavior, interventions for residents at risk, how to initiate an elopement care plan, and obtaining orders/consent for wander guard devices if indicated.
• The facility's ADM initiated an in-service to Social Services, ADON, MDS nurse, Activities Director, Central Supply, Admissions Assistant/receptionist, Accounts payable, occupational therapist on steps to take when a resident is newly admitted or exhibits new wandering/exit seeking behaviors, including elopement risk assessment, notification of MD, obtaining orders/consent for wander guard device, monitoring for exit seeking behavior every shift, initiating elopement care plan, and every 2 hour visual checks.
• The facility ADM and DON reviewed facility elopement policy and procedure, related to the recent incident, with the Medical Director.
• The facility's RCRN provided education to the DON and ADM on what is considered elopement and the reporting requirements.
• 13 residents at risk for elopement were monitored by Licensed Nurses for episodes of exit seeking behavior every shift and documented in the MAR.
• The facility's Licensed Nurses initiated the completion of head count rounds at the beginning of the shift and documented on the census sheet for residents not identified as at risk for elopement.
• The facility's ADON, DON and RN supervisor initiated validation of the completion of daily head count monitoring by Licensed Nurses, with corrections communicated as needed.
• The facility's maintenance supervisor/designee checked the operation of door monitors and resident wandering system (Wander Guard System) and will continue to check weekly.
• A new measure was put in place when the Maintenance Director installed exit door alarms on 3 of the 4 exit doors; when the doors are opened an alarm will sound to alert staff.
• The facility's Social Services Director, Maintenance Director and DON initiated in-service to Licensed Nurses and CNAs regarding the new alarm doors, emphasizing response to alarms and use of only the main entrance for entry/exit.
• The facility's IDT initiated daily review of new admissions and residents with new wandering/elopement behavior to ensure care plans are updated and interventions implemented (monitoring, increased visual checks, individualized activity plan, wander guard).
• The facility's HIM initiated admission audits and change of condition audits for residents with new wandering/exit seeking behaviors, including completion of elopement risk assessment, IDT note, orders/consent for wander guard, care plan for risk of elopement, monitoring for exit seeking behaviors every shift, updating elopement binder with resident's picture and identification, and visual checks. Missing items are reported to DON/designee.
• The facility's HIM will present elopement-related audits to the QAPI committee for review with Medical Director, evaluation, trending and tracking until compliance is reached.