Failure to Provide Adequate Supervision and Person-Centered Interventions Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision and person-centered care plan interventions, resulting in elopement incidents for two residents identified as at risk for elopement. Both residents had documented cognitive impairments and histories of confusion, agitation, and wandering behaviors. Despite these risk factors, the facility did not consistently update or revise elopement assessments or care plans following significant changes in the residents' conditions or after incidents indicating increased risk. One resident, with diagnoses including metabolic encephalopathy, repeated falls, and diabetes, exhibited fluctuating cognition, periods of confusion, and a history of wandering and falls. The resident was found unsupervised in restricted areas of the facility on multiple occasions, including the basement and another floor, despite care plan interventions such as a wanderguard and supervision requirements. Documentation showed that after these incidents, the facility did not complete timely elopement observations or update the care plan to reflect the increased risk or necessary interventions. Another resident, diagnosed with dementia and severe cognitive impairment, was found unsupervised in a closed and unstaffed unit's break room. The resident's care plan and elopement risk assessment were not updated after documented episodes of increased confusion, sundowning, and behavioral changes. The care plan failed to reflect a resident-centered approach or include appropriate interventions until several months after the incident. Staff interviews revealed inconsistencies in the identification and monitoring of residents at risk for elopement, lack of updated wander lists, and unclear responsibilities for the wander management program.
Removal Plan
- DON/Designee will immediately re-evaluate Resident R6 and Resident R111 for elopement risk.
- DON/Designee will re-evaluate all residents for exit seeking behaviors.
- Nursing staff/Designee will provide every one-hour safety checks on all residents. Residents who are at risk of elopement will have every one-hour safety checks ongoing to ensure resident safety.
- DON/Designee will provide appropriate supervision levels for all residents in their orders and person-centered care plans to include interventions such as resident specific activities such as 1:1 interactions, cards, outside to courtyard with supervision, etc. Review and update quarterly, annually or with any significant changes or with any event where elopement is an identified risk.
- DON/Designee will audit appropriate supervision levels.
- DON/Designee will thoroughly investigate all incidents for root cause analysis and follow up with interventions.
- DON/Designee will audit all incidents.
- DON/Designee will implement interventions for residents identified as an elopement risk to prevent residents from eloping.
- DON/Designee will audit all interventions.
- DON/Designee will update elopement assessments quarterly, annually or with any significant change or with any event where elopement is an identified risk.
- Security/Designee to take photographs of residents upon admission to the facility to ensure updated wander books, if they are at risk of elopement. Security providing all nursing units with wander books, with photographs and names/room numbers of residents, and will be updated upon resident's admission and/or discharge.
- Policy for Wanderguard and elopement has been reviewed and facility will add addendum regarding supervision levels and also Security/Designee taking photos of residents upon admission to the facility to ensure resident at risk of elopement are placed in wander books are updated with names/room numbers. Wander books to be updated upon resident admission/discharge and with room changes.
- Staff Educator/Designee will educate all staff on policies for Elopements, Assessments, Care Plan, Supervision, and Accidents.
- Facility will review incidents at QI/QAPI.