Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
The facility failed to provide adequate supervision to a resident identified as an elopement and wandering risk, resulting in the resident exiting the facility unsupervised. The resident, who had a diagnosis of Schizophrenia and severe cognitive impairment as indicated by a BIMS score of 4, was last seen in the dining room by staff. Despite being equipped with a wander guard bracelet, the resident was able to leave the facility through a kitchen door that was not equipped with a wander guard alert system, unlike other facility exits. The door had a keypad lock, but it was accessible from the dining area and not properly secured to prevent resident exit. Staff did not immediately notice the resident's absence. The resident's walker was left in the dining room, and staff initially assumed the resident had returned to his room. It was only after a phone call from the resident's family and subsequent checks that staff realized the resident was missing. A facility-wide elopement alert was then announced, and staff began searching the premises and surrounding area. The resident was located approximately one mile from the facility, having crossed a busy four-lane highway, and was returned after being unsupervised for about two hours. Interviews with staff and family confirmed that the resident had a history of exit-seeking behavior and had previously expressed a desire to go home. Staff had observed the resident attempting to open exit doors on multiple occasions. The facility's policy required staff to report any resident attempting to leave or suspected of being missing, but in this instance, the resident was able to leave undetected due to the lack of a wander guard system on the kitchen door and insufficient supervision in the dining area.
Removal Plan
- RN #2 performed a head-to-toe assessment with the resident's daughter, Executive Director, and DON present. There were no visible physical injuries.
- A 100% audit of all Wander/Elopement Risk residents were assessed for placement and proper functioning with no adverse findings.
- All the facility's entrance and exit door's alarm systems were checked. All the alarms were functioning properly.
- Resident #1 checked for wander guard placement and properly working. His wander guard was intact and working properly.
- Head-to-toe assessment of Resident #1 completed by the Unit B Manager and DON. There were no negative findings.
- Resident #1 was interviewed by the Unit B Manager. No negative statements were made by the resident.
- Upon Resident #1's return he was placed on 1:1 location monitoring x (times) 72 hours then tapered down to every 15 minutes then every 30 minutes then every hour. The Unit Manager, DON, and Social Services will determine when the resident may be removed from 1:1. The resident was placed on 24 hours charting for the nurses to document and notifying the MD/NP of any significant changes in the resident physical or mental status.
- A keypad lock was placed on the kitchen entrance door in the dining room by the Housekeeping Supervisor. The Housekeeping Supervisor replaced the old door handle on the kitchen door next to Unit-B with a keypad. The code will be given to dietary workers and key staff.
- The Maintenance Supervisor contacted Systronic Alarms Systems on installing a wander guard alarm on the kitchen door leading to the loading dock. A representative from the company will be at the facility.
- Resident #1 was moved closer to the nurses station. He moved from B 118P to B 108P. The Elopement Wander guard book reviewed. The Elopement Book was correct. A 100% check of the Wander/Elopement Risk were assessed for placement and proper functioning.
- The Dietary Workers on shift during the time of the incident received 1:1 Educational In-Services on Exit Doors in the kitchen and written corrective counseling by the Executive Director.
- Educational In-services for the facility's staff conducted by the Staff Development/Executive Director were initiated and included: a) Exit Doors in the kitchen b) Resident's Rights c) Abuse Prevention and Reporting d) Abuse and Neglect e) Residents expression to go home f) Missing Resident/Elopement.
- The Unit B Manager re-schedule Resident #1's eye appointment. Resident's appointment is scheduled as a follow-up consult visit to rule out retinal vein occlusion with macula edema to the left eye.
- Resident #1's care plan and pain assessment up-dated. Social Services Director preformed a Trauma Screen.
- The facility prepared a formal letter to mail to each resident's representative. The letter requests that during visits, if the resident expresses wish to leave the facility or return home, the family should inform nurse management, the Executive Director, or Social Services.
- We had a Family Meeting with Resident #1's daughter. The daughter did not express any concerns about her father's care or safety with the facility.
- Nursing will review 24 hour progress notes on the following week day and/or Monday following the weekend for any resident's voicing wanting to go home or exhibits exit seeking behavior to ensure proper intervention are in place.
- A QAPI was implemented with an emergency QA meeting reviewing Resident #1's incident.