Failure to Investigate and Prevent Multiple Resident Elopements
Penalty
Summary
The facility failed to thoroughly investigate multiple elopement incidents involving three cognitively impaired residents who were at risk for wandering. Each of these residents either wore a wander alert bracelet or was known to be mobile and confused, yet managed to exit the facility unsupervised. In one instance, a resident with severe cognitive impairment and a wander alert bracelet exited the building, setting off the door alarm, but staff did not respond appropriately. The resident was found wandering in the parking lot by a staff member who was outside on break. In another case, a resident with similar cognitive impairment and a wander alert bracelet was found unsupervised in the parking lot by a visitor, with the facility unable to determine how the resident left despite the bracelet. A third resident, also severely cognitively impaired and mobile, exited the facility without staff knowledge and was only noticed by a staff member leaving the premises. The facility's Quality Assurance and Performance Improvement (QAPI) program did not identify or address the systemic issues that allowed these elopements to occur. The investigations into the incidents did not uncover critical failures, such as the lack of an audible alarm on exit doors or the absence of monitoring to prevent residents from following visitors out. The QAPI committee did not develop or implement a Performance Improvement Plan (PIP) to address the repeated incidents, and there was a lack of comprehensive root cause analysis. The Administrator and DON acknowledged that elopement drills were not conducted after the incidents and that only one QAPI meeting had been held since the Administrator's employment began. The facility's response to the incidents was limited to updating care plans and providing some staff education, without systemic corrective actions. Interviews with facility leadership and staff revealed gaps in supervision, monitoring, and understanding of elopement risks. The Administrator was unaware of certain vulnerabilities, such as residents being able to exit with visitors or the nurse's station being frequently unattended. The DON and other staff confirmed that not all residents at risk had appropriate interventions in place, and that the facility's investigations did not fully address the underlying causes of the elopements. The lack of effective QAPI oversight and failure to implement systemic changes created an ongoing risk for further unsafe wandering and elopement among cognitively impaired residents.
Removal Plan
- Educated staff on residents at risk for elopement and elopement interventions.
- Staff educated on new process for doors to be locked and someone will have to allow entrance and exit of residents, families and guests.
- Staff member must observe doors until they are fully closed.
- Staff educated on elopement procedures including verifying all residents are accounted for prior to shutting alarm off.
- Staff was educated on all residents who are at risk for elopement along with elopement interventions, behavioral sign and symptoms of elopement and elopement interventions.
- Elopement drills will be done on all shifts.
- Elopement drills were conducted.