Failure to Prevent Resident Elopement Due to Lack of Timely Intervention
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not implementing measures to prevent elopement for a resident who had recently begun exhibiting exit-seeking behaviors. The resident, who had diagnoses including bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, began displaying new behaviors such as packing belongings and waiting at the front door, believing her family was coming to get her. Despite these documented behaviors, staff did not update the resident's care plan or implement additional supervision or wander management interventions prior to the incident. On the day of the incident, the resident exited the facility unnoticed and unsupervised. She was found approximately fifteen minutes later by a CNA, sitting in the passenger seat of the CNA's car in the facility parking lot, which was located near a busy four-lane boulevard. Staff were unaware of the resident's absence until she was brought back inside. There was no incident report completed at the time, and no head count or missing resident protocol was initiated following the event. Interviews with staff confirmed that the resident's care plan had not been updated to reflect her new exit-seeking behaviors, and that elopement drills or additional supervision had not been implemented. The facility's policy required identification and intervention in situations where neglect was more likely to occur, including increased supervision for residents at risk. However, despite multiple staff members observing and documenting the resident's exit-seeking behaviors in the days leading up to the incident, no changes were made to her care plan or supervision level. The lack of timely intervention and failure to follow facility policy resulted in the resident being able to leave the facility unsupervised, placing her at risk.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for residents with behavioral changes that verbalize leaving the facility, exit seeking, wandering, and packing belongings should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all residents who were determined to be at risk for elopement to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident #1 to confirm details of the elopement.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and exiting the facility and to notify staff if a resident verbalizes thoughts of leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. All routine staff who cover the receptionist area were also in-serviced.
- A 100% audit of elopement binders was conducted by the Social Service Department to ensure the binders' information was reflective of all residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with key facility leadership and the Medical Director to review the incident and corrective actions.