Failure to Prevent Elopement and Provide Supervision Results in Resident Injury
Penalty
Summary
A facility failed to provide adequate supervision and accident prevention for a resident identified as an elopement risk. The resident, who had diagnoses of Alzheimer's disease and dementia and was assessed as lacking capacity for decision-making, had a documented history of wandering and previous attempts to leave the facility without informing staff. The resident's care plan specifically identified the risk for elopement and included interventions such as anticipating needs, encouraging activity participation, and frequent visual checks for safety. Despite these documented risks and interventions, the resident was left unsupervised in a wheelchair in the hallway after being assisted to the restroom, and staff did not maintain the required level of monitoring. On the day of the incident, the resident was observed propelling herself down the hallway and was later seen in the front lobby. The facility's front exit door was left wide open and unmonitored when the receptionist left her post unattended to use the restroom. No staff were present to observe or redirect the resident, and the door alarm was not responded to in a timely manner. The resident exited the facility unsupervised, traveled to an adjacent property, and fell from her wheelchair onto the street. The incident was not immediately noticed by staff, and the resident was found by a passerby who called emergency services. As a result of the elopement and fall, the resident sustained multiple injuries, including fractures to the nose, jaw, and ribs, a laceration to the lip, a hematoma, and damage to dental implants. Interviews with staff and review of records confirmed that the facility did not follow its own policies and procedures regarding supervision, elopement prevention, and door monitoring. The lack of supervision and failure to ensure the function and monitoring of exit doors directly led to the resident's elopement and subsequent injuries.
Removal Plan
- Resident 1 was placed on 1:1 supervision with staff educated on supervision until a safe plan is determined by the IDT.
- In-service education was provided to the weekend and evening receptionist regarding not leaving their post unattended.
- In-service education regarding monitoring/supervision, wandering, and elopement policy was provided to the receptionist and facility staff on shift, including licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel.
- Facility doors were checked for appropriate function by the Maintenance Director.
- A head count of all in-house residents was initiated and all residents were accounted for.
- Elopement assessments were completed on all residents by the DON/designee.
- Two residents identified at risk for elopement were reviewed by the DON/designee for appropriate care plan interventions.
- In-service education regarding wandering and elopement was provided to facility staff, including licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel. Staff on leave or PRN will be in-serviced on their next scheduled shift.
- An IDT meeting was conducted for the two residents identified as at risk for elopement.
- The DON or designee will audit new admissions with elopement risks and ensure appropriate interventions are in place.
- The SSD or designee will review all new admissions to ensure an elopement risk assessment has been completed, and those residents identified at risk are updated in the Elopement binder. Audits will be conducted until substantial compliance is achieved.
- New hires will receive education on wandering, elopement, and resident safety by the DON, SSD, or designee(s) upon hire and annually thereafter. Ongoing in-service trainings regarding wandering, elopement, resident safety, and resident monitoring/supervision will be performed.
- Elopement risk binders were reviewed and updated by the DON and Administrator. Binders are available at each nursing station and reception area, updated by the SSD with oversight by the DON.
- Elopement code drills were initiated on all shifts and will continue by Administrator/DON and/or DSD.
- A check of facility doors and alarms was performed by the Maintenance Department to ensure function and securement. Frequency increased.
- A check of facility doors and alarms will be performed by the Maintenance Department until substantial compliance is achieved. Any findings will be corrected immediately and trends reported to the QA/QAPI Committee.
- The QAPI Committee will review and discuss elopement and supervision for all residents during QAPI meetings to determine effectiveness and provide feedback and program modification until compliance is maintained.