Failure to Investigate and Report Resident Elopement
Penalty
Summary
The facility failed to initiate a thorough investigation into an allegation of neglect and an incident of elopement involving one of six sampled residents. On the specified date, a resident exited the facility unsupervised and was found sitting in a staff member's car in the facility parking lot. The resident had left the building unnoticed by staff during a shift change and was able to access an area adjacent to a busy four-lane boulevard. The staff member who discovered the resident escorted her back into the facility and notified the appropriate personnel, including the Executive Director and the Director of Nursing Services. Despite the incident, there was no documentation of the elopement in the facility's accident/incident log, and no incident report was completed. Multiple staff members, including LPNs and the Unit Manager, confirmed that they were aware of the resident's unsupervised exit but did not participate in any investigation or initiate missing resident procedures. No head count of residents was conducted, and the event was not reported to the State Agency as required. The Executive Director stated that the incident was not considered an elopement because the resident claimed she was waiting for her brother, and therefore, no report was made to any agencies. The resident involved had a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, but her most recent assessment indicated no cognitive impairment and no documented wandering or exit-seeking behaviors. The facility's policies required immediate investigation and reporting of such incidents, but these procedures were not followed. The failure to conduct a thorough investigation and report the incident placed the resident and others at risk, as identified by the State Agency, which cited the facility for failing to meet regulatory requirements regarding the investigation and prevention of alleged violations.
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 verbalizing to leave the facility, exit seeking, wandering and packing belongs 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 risk 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. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the 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. In addition to all routine staff who cover the receptionist area, the receptionist was in-serviced by the Executive Director.
- 100% audit of elopement binders were 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 the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social Service Assistants and Medical Director. The IP nurse was present by phone.