Failure to Prevent Elopement and Timely Response for At-Risk Resident
Penalty
Summary
A resident with a history of psychoactive substance abuse, alcohol-induced disorder, generalized muscle weakness, and unsteadiness on feet was admitted to the facility and assessed as being at risk for elopement. Despite this assessment, the facility failed to develop a care plan or implement interventions to address the resident's elopement risk. The resident had a physician's order allowing out on pass (OOP) privileges, but the order was non-specific, lacking details about duration, accompaniment, or supervision requirements. The resident left the facility independently for an OOP and did not return at the expected time. Facility staff did not initiate a search for the resident when he failed to return as scheduled, nor did they notify the DON, administrator, or local authorities in a timely manner. Documentation shows that the resident's absence was noted, and attempts were made to contact him by phone, but no further action was taken to locate him or escalate the situation according to facility policy. The lack of a clear care plan and failure to follow established elopement risk procedures contributed to the delay in recognizing and responding to the resident's absence. Interviews with staff and review of facility policies revealed that staff were unclear about the procedures to follow when a resident did not return from OOP. The facility's policies required timely searches and notifications, but these were not carried out. The resident remained missing for an extended period before the incident was reported to the appropriate authorities, including the police and the Department of Public Health. The failure to implement and follow elopement risk protocols resulted in an Immediate Jeopardy situation.
Removal Plan
- All residents with out on pass order were reviewed and updated including the duration, purpose, and companion. If the resident will not return after specified duration, facility will call resident/family/companion for update on whereabouts and the time of return. If resident requests to go out on pass independently, resident must meet all of the following criteria to be considered eligible and Interdisciplinary Team will review request to go out unaccompanied and document in Interdisciplinary notes: Cognitive Competency (Recent BIMS), Behavioral Stability (No recent history of elopement), Medical Stability (Medically cleared by Attending Physician), Functional Mobility.
- MDS Coordinator and Registered Nurse Supervisor re-assessed all residents with out on pass order and baseline care plan was updated. Elopement Risk Assessment was done for all residents. Residents were identified as low risk or high risk for elopement.
- Elopement Risk Policy and Procedures was revised and updated. The licensed personnel were in-serviced and educated regarding timely assessment and identification of residents with high risk of elopement. Any episode of elopement reported and communicated to the Director of Nursing and Administrator so the facility leadership will be able to inform residents family, physician, regulatory Police Department, Ombudsman, California Department of Public Health and other regulatory agencies.
- Director of Staff Development/Director of Nursing in-serviced the licensed personnel regarding Policy and Procedure for elopement to emphasize reporting to local police, administrator, and residents' representative within 2 hours and to California Department of Public Health within 24 hours when resident elopement.
- All residents with out on pass order were reviewed and updated including the duration, purpose, companion, and return time. A log was available to both nursing stations, regarding the time out and estimated time to return to the facility.
- Residents on high risk for elopement are potentially affected by the deficient practice. Residents identified as high risk were re-assessed, care plan was developed and implemented, including monitoring every two hours. Log was available in the nursing station.
- An in-service was provided to Licensed Nurses and direct care givers by the Director of Staff Development and Social Service Director pertaining to: How to alert staff about resident elopement or missing, How to locate or search the resident, Reporting to governing agencies within 2 hours and CDPH within 24 hours.
- The Director of Nursing/Designee and Director of Staff Development conducted in-service to Licensed Nurses and Certified Nursing Assistants pertaining to the following: Revised Policy and Procedure for Out on Pass, Physician order for out on pass, Duration and companion, Protocol if the resident did not return after specific duration, Resident's decision against medical advice.
- Policy and Procedure for Elopement.
- During daily angel rounds the Department Managers will check the out on pass log and discuss in the daily stand-up meeting.
- The Director of Nursing Services/Registered Nurse Supervisor is responsible for monitoring the residents on a daily basis to ensure that the deficient practice will not be impacted. Results of the findings will be submitted and discussed to QAPI Committee during the monthly/quarterly QAPI meeting of its effectiveness.