Failure to Maintain Elopement Prevention Protocols and Supervision
Penalty
Summary
The facility failed to provide a safe environment for residents identified as being at risk for elopement, as evidenced by multiple lapses in the implementation of its elopement prevention policy. Observations revealed that the front entrance doors were accessible by sensor and were not consistently monitored or secured, with front desk staffing not covering all hours when the doors were unlocked. Staff members assigned to the front desk were not always aware of their responsibilities regarding monitoring the entrance or the procedures for elopement prevention. Additionally, there was no wander guard system in place to prevent residents from exiting through the front door. Record reviews showed that the Elopement Risk Manuals, which were supposed to contain up-to-date Missing Resident Identification Forms for all residents at risk, were incomplete or missing forms for several high-risk residents across multiple units. Staff interviews indicated a lack of awareness among some nursing assistants regarding which residents were at risk for elopement and where to locate the Elopement Risk Manuals. Furthermore, the process for updating these manuals was not consistently followed, and some staff members responsible for updates were unclear about the procedures. Education and preparedness for elopement prevention were also insufficient. Not all staff had received required training on elopement prevention, and attendance at in-service education events was incomplete. After an actual elopement incident involving a resident, no additional education was provided to staff. Elopement drills were conducted with limited staff participation, and there was a lack of follow-up education after incidents. These deficiencies affected a significant number of residents identified as high risk for elopement.