Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was identified as being at risk for elopement or unsafe wandering. The resident, who had diagnoses including aphasia, heart failure, and a history of stroke, was noted to rarely understand or be understood and had been assessed as at risk for elopement on multiple nursing admission evaluations. However, a wandering observation tool completed shortly before the incident indicated no history of wandering, and physician orders did not include interventions related to wandering or elopement risk. On the day of the incident, the resident was observed to be agitated, pacing the halls, and not at his baseline. Staff last saw the resident at the nurses' station, and shortly thereafter, the resident exited the facility through a side door. The stairwell alarm sounded but was silenced by an Environmental Services employee who did not properly check the stairwell or notify other staff. The resident was later found outside the building on the road, engaged in a physical altercation with a passerby. Staff intervened and escorted the resident back into the facility, where a small open area was found on his wrist. Interviews and documentation revealed that staff did not respond appropriately to the alarm, and the resident was able to leave the premises without supervision. The facility's investigation confirmed that the alarm was silenced without ensuring resident safety, and the resident's care plan and risk assessments were not updated in a timely manner to reflect his increased agitation and risk of elopement. This failure resulted in an immediate jeopardy situation for the resident.
Removal Plan
- Affected Resident was escorted back into the facility. Wanderguard was then placed on resident. Physician was notified. Body assessment completed and skin tear to resident's right wrist was discovered. Treatment applied. Resident was transferred to ED for evaluation and treatment. Resident returned with a positive UA but not being treated.
- Facility Wide Headcount was conducted by nursing department and all residents were accounted for.
- All Alarming Doors were audited to ensure functionality.
- After return from hospital immediate intervention of 1:1 was placed on resident and will be until adjustment to new medications is accomplished.
- Elopement Books were updated to include affected resident.
- Elopement Care plan and Orders were updated on all like residents.
- Whole House Education was completed on Elopement Policy, Responding to Alarms, Code [NAME] and inspecting any stairwells or any exit path by Nurse Educator/designee.
- Pharmacist Consultant reviewed medications, no medication changes.
- Psychiatric consultation was made, and medication adjustments were made. Resident was prescribed Lexapro.
- Newly admitted residents are screened for elopement risk upon admission, quarterly and as needed and care plans and assessments done accordingly. Any resident deemed at risk for elopement will have a Wanderguard placed.
- Facility Medical Director was notified of the Immediate Jeopardy and Abatement Plan.
- Daily Door Alarm Audits will continue by Maintenance Department or designee.
- Elopement Drills will be conducting weekly for two months, alternating shifts for two months.
- The Plan of Correction will be monitored at the Monthly QAPI Committee Meetings monthly for the next three months. Reviewing all door audits, elopement drills, new admissions for elopement assessments and reviewing the Elopement Policy as needed.
- Results will be submitted to QAPI.