Failure to Prevent Resident Elopement Due to Inadequate Supervision and Environmental Hazards
Penalty
Summary
A deficiency occurred when a resident with a complex medical history, including sequelae of intracerebral hemorrhage, hypertension, diabetes, and cognitive impairment, was able to elope from the facility. The resident had a care plan that identified him as an elopement risk due to a history of attempts to leave the facility unattended. Interventions listed included distraction, structured activities, reorientation strategies, and the use of a wander guard. However, on the day of the incident, the resident was able to leave the facility premises without staff knowledge. Staff interviews and record reviews revealed that the resident was last seen by an LVN, who noted the resident was searching for someone and then ambulated away. Later, the resident's spouse contacted the facility after receiving a call from the resident, who was outside and disoriented. Facility staff initiated a search and found the resident approximately 500 feet from the building, sitting on the ground. The resident was assessed and found to have no physical injuries at that time, but was noted to be more confused than usual. The resident was sent to the hospital for further evaluation due to an elevated INR and was subsequently treated for a subdural hematoma. Observations of the facility environment revealed that the back door between two halls was always kept unlocked, and the patio area had no gate, allowing direct access to the parking lot and surrounding areas. The lack of physical barriers and the absence of staff at the front entrance after the concierge left contributed to the resident's ability to exit the building unnoticed. The facility's elopement evaluation for the resident did not identify him as an elopement risk, despite his care plan indicating otherwise, and the unsecured environment allowed the incident to occur.
Removal Plan
- Resident was assisted to re-enter the facility and assessed per RN with no injury noted.
- The MD and responsible party were notified with new orders for resident to be sent to the ER due to deviation from baseline mental status.
- One-on-one initiated pending ER transfer, wander guard placement prior to ER transfer.
- Resident returned from hospital and discharged home with wife.
- The resident's care plan was updated to include personalized interventions and potential triggers for exit seeking behavior by the DON and/or Social Worker.
- All available staff were trained on elopement procedures and all other staff will be trained before their next scheduled shift on elopement procedures and managing exit seeking behaviors by the DON and/or designee.
- Social Worker was educated by DON on resident specific care plan interventions and identify triggers related to exit seeking behaviors.
- An Elopement Drill was conducted on each shift by DON and/or designee.
- Elopement Risk book reviewed and updated by Social Worker/Designee. This book contains identification information on residents at risk for wandering. Picture of resident as well as face sheet are included. Book is available to all staff with copy at receptionist desk and on each nursing unit.
- All available staff were trained on the elopement book by DON/Designee. All other staff were trained before their next scheduled shift on the elopement book.
- All doors with the wander guard system were checked to ensure proper function by facility maintenance staff. All door wander guards were functioning properly.
- Elopement risk was completed on all residents by DON/Designee. Any resident identified with elopement risk had interventions added. These include but are not limited to Wander Guard, Secure Unit, frequent checks, and the Care Plan updated. These updates reflect resident specific interventions. Residents with any risk had interventions implemented.
- Security Staff job opening posted on hiring platforms for nighttime rounding, monitoring interior and exterior of facility examining doors to ensure they are functioning, secured and untampered.
- All Security job openings were filled, and orientation completed. All rounding sheets reviewed with no concerns, elopements, or significant findings.
- Elopement policy was reviewed with no updates required by the Regional Clinical Consultant.