Failure to Prevent Resident Elopement Due to Inadequate Supervision and Protocol Lapses
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, difficulty walking, pelvic fracture, and cognitive impairment was able to leave the facility without a physician's order for a leave of absence (LOA) and without staff supervision. The resident, who required one-person assistance for ambulation and had a moderately impaired cognitive status as indicated by a BIMS score of 10, exited the third floor via elevator and walked out the front entrance using a walker. The resident was not identified as having an LOA order in the clinical records, and there was no documentation of staff being notified or a sign-out process being followed. Facility policy required that residents at risk for wandering or elopement have care plans with specific interventions and that staff intervene if a resident attempts to leave. However, the receptionist on duty did not recognize the resident as a facility resident, mistaking her for a visitor due to her appearance. The receptionist was distracted by personal computer use and failed to follow the protocol of ensuring all residents and visitors sign out and wear visitor badges. Surveillance footage confirmed that the receptionist opened the door for the resident, who then left the premises unchallenged. Staff interviews revealed that the assigned nursing assistant was aware the resident wanted to walk but did not clarify the resident's intentions or monitor her whereabouts. The resident was later found approximately 1.2 miles away in a busy area after being missing for about two hours. The failure to provide adequate supervision and to follow established LOA and visitation protocols resulted in the resident leaving the facility unsupervised, placing her at high risk for injury.
Removal Plan
- Resident was assisted back to the Center and assessed by RN Supervisor for injuries.
- The Center completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for.
- The Nursing Administration held huddles with staff to discuss residents who go on frequent LOAs and signs and symptoms that may indicate risk for leaving the Center without staff notification.
- Shift RN Supervisor provided immediate education to receptionist on duty.
- RN Supervisors were educated on the completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee.
- Staff were educated on signs and symptoms that may indicate a risk of elopement.
- Reception/security staff were educated on the process of each visitor receiving a badge that must be returned prior to door being opened and visitor leaving the premise.
- Staff educated on elopement/missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premises and the surrounding areas, notification processes including local police department.
- Staff educated on elopement drills including how often and expected response.
- All the training above will be added to our general orientation schedule for all new future employees.
- Residents with a current unsupervised LOA order were re-educated on the LOA policy/agreement and understood the sign out process with both the nursing staff on the unit.
- Auditing census compared to headcount every 4 hours for 3 days then every shift for 14 days then daily. All variances will be reported to the QAPI Committee monthly.
- Random audit of five visitors to ensure compliance with the visitor pass system two times daily for 14 days then daily for two months. All variances will be reported to the QAPI Committee monthly.
- Daily audit of LOA log to ensure reception/security staff are checking for clearance to leave the Center. The audit will be completed daily for three weeks with all variances reported during the clinical meeting.
- The QAPI Committee will make recommendations to ensure continued compliance. Upon sustained compliance, the QAPI Committee will recommend the reduction or resolution of the audits and the reception/security staff.