Failure to Prevent Resident Elopement Due to Inadequate Supervision and Risk Identification
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment to prevent the elopement of a resident who had documented new wandering and exit-seeking behaviors for at least a week. The resident, who had diagnoses including bipolar disorder, anxiety, schizophrenia, a history of falls, and was assessed as at risk for falls and requiring supervision for walking, exited the facility unnoticed and was found sitting unsupervised in a staff member's car in the parking lot. The resident had been observed packing belongings, expressing confusion, and making statements about leaving, but these behaviors were not identified as exit-seeking or elopement risk by staff. Despite multiple staff members observing the resident's behavioral changes, including repeated trips to the front entrance and packing bags, the care plan was not updated to reflect the new risk, and no interventions such as wander management devices or increased supervision were implemented prior to the elopement. Documentation of the resident's change in behavior was reported to the primary healthcare provider, who ordered a urinalysis, but the facility did not recognize or address the increased risk of elopement. Staff interviews revealed a lack of awareness and action regarding the resident's behaviors, and no incident report was completed after the resident exited the facility. Additionally, facility policies and procedures were not followed, as evidenced by the absence of an updated care plan, missing elopement binders at the nurses' station, and lack of head counts or elopement drills following the incident. The front entrance could be opened with a code, and the receptionist, who was aware of the resident's behaviors, left the desk unattended without ensuring coverage. The facility did not report the incident to the State Agency in a timely manner, and there was no thorough investigation or immediate implementation of elopement precautions for the resident prior to the event.
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 the receptionist area 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 vice Assistants and Medical Director. The IP nurse was present by phone.