Resident Elopement Due to Inadequate Supervision and Lapse in Monitoring
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including unspecified dementia and acute respiratory failure, was able to leave the facility undetected. The resident required assistance with all activities of daily living and was incontinent of bladder. On the day of the incident, the resident was last seen in his room after receiving a shower in the morning. Staff noted his absence when his lunch tray was delivered and he was not present in his room. Upon realizing the resident was missing, staff initiated a search of the facility and its grounds, and a code for a missing resident was called. Law enforcement, the resident's guardian, and the medical doctor were notified. The resident was eventually found by law enforcement approximately 5.2 miles away from the facility after boarding a city bus and being missing for about eight hours. The area where the resident was found was described as a high-traffic location with cross streets, increasing the risk of harm due to the resident's vulnerability and cognitive impairment. Interviews with staff revealed that the facility had a high volume of visitors on the day of the incident, and it was suggested that the resident may have followed a visitor out of the building. At the time, the resident did not have a wander alert system bracelet in place, and staff were unaware of his exit until the lunch tray was delivered. The facility's protocols for monitoring and supervising residents at risk for elopement were not effectively implemented, resulting in the resident's undetected departure.
Removal Plan
- Nurses completed a head count using the facility's census to ensure no other residents were missing, verified by the nursing supervisor.
- Resident was reevaluated by the psychiatrist and new orders were received.
- Reeducation regarding the prevention of elopement was initiated for the staff by the Director of Nurses (DON).
- All nursing staff on all shifts received education regarding residents who exhibit exit-seeking behavior, the risk of elopement, and the need for adequate supervision to ensure resident safety.
- Unit Managers, supervisors, and/or designee(s) and/or MDS Coordinator(s) re-evaluated residents at risk for elopement by completing a new elopement risk screening form.
- MDS Coordinator and/or designee reviewed and updated the care plans of the residents at risk for elopement to reflect the current elopement risk.
- Nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee(s).
- A Root Cause analysis was completed using the Five Whys to develop new approaches to prevent reoccurrence.
- Facility conducted an AdHoc Quality Assurance Meeting to review the Performance Improvement Plan ensuring proper interventions are put in place.
- The facility conducted an elopement drill on every shift.
- Staff were re-educated on the Elopement and wandering, exit seeking resident policy.
- DON, ADON, and designee completed elopement risk screening on active residents and reviewed their plan of care to ensure appropriate interventions are in place, and the plan of care was updated.
- Facility wide audit of the elopement screenings identified new residents that triggered for elopement risk.
- Residents triggered for at risk for elopement have orders for a wander alert system to be put in place.
- Orders were obtained from the physician for psych reevaluation for residents triggered for elopement risk.
- The elopement book was updated with new pictures of residents triggered for elopement risk.
- Elevator keypads installed on the elevators by the Elevator Company.
- A keypad/alarm installed at the door leading to the lobby by the alarm company.
- Elopement drills are done on every shift.
- The Maintenance Director or designee to conduct Safety rounds Log to check exit door, screamer alarms and outside gates.
- Residents with new behaviors of exit seeking and wandering will be added to the elopement risk book that is kept at the nursing station and is accessible to all staff. The behaviors will be added to the resident's care plan and the Kardex.
- Nursing staff will communicate during the shift to shift report any resident who exhibits behaviors to leave the facility, and the safety measures put into place.
- The nurses and nursing supervisors will use the facility census to conduct the headcount of the residents in their respective unit during shift change and they will sign the census to validate that the count is correct, and all residents are accounted for.
- The CNAs will conduct rounds every two hours to ensure the residents are safe and accounted for. CNAs will report to the nurse immediately if unable to locate a resident. Facility protocols for missing residents will be used immediately to locate the residents.
- New admissions elopement evaluations will be reviewed during clinical meetings to ensure elopement interventions are in place for residents that are at risk and the facility guidelines are followed. Nursing Supervisors will review the new admissions elopement evaluation for compliance.
- The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place.
- Residents with new behaviors of wandering, exit seeking will be reassessed by the ADON, Unit Managers, Supervisors or designee for a risk for elopement.
- The DON, Administrator, ADON and/or designee will enforce disciplinary action for facility staff who fail to follow the elopement policy and procedures.
- New hires will receive education on wandering, elopement, and resident safety by the DON, ADON or designee(s).
- Education Target goal is 100%.
- DON and ADON reeducated employees on the facility's policy & procedures as it is related to elopement and residents' safety.
- Staff members participated in the elopement drills.
- Facility compliance with elopement drills was tracked and increased.
- All elopement elements put into place were verified and the facility is in compliance.
- After the facility wide audit of the elopement screening, the facility identified new residents who triggered for elopement.
- A QAPI (Quality Assurance and Performance Improvement) review for follow-up was done and all elements were verified.
- The facility will conduct an elopement drill.
- The DON, ADON, and administrator will review the clinical record of any residents with behaviors of exit seeking and wandering to ensure the facility policy and procedures are implemented and followed, and residents have remained safe at the facility.
- Review the findings during the QAPI meeting.
- The DON, ADON/designee will conduct a quality review of residents on each unit.
- The findings of these reviews will be reported in the next Risk Management/QA Committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring by the Regional Director of Clinical Services when completing their quality systems review.
- The committee reviewed the plan and determined the removal plan has been implemented effectively.