Failure to Prevent Elopement and Identify At-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent accidents, specifically elopement, for two residents. One resident, who was assessed as being at risk for elopement due to cognitive impairment, poor decision-making skills, and exit-seeking behavior, was able to leave the facility unsupervised. This resident exited the building when a CNA was assisting other residents to a smoking area, and the door was opened using a code that temporarily disabled the Wanderguard alarm system. The resident was not identified as a smoker and was not being directly supervised at the time, allowing him to leave unnoticed until another resident alerted staff. Another resident, also with cognitive impairment and a history of exit-seeking behavior, was not properly identified as an elopement risk. Although this resident had previously been assessed as at risk and had a Wanderguard device ordered, the device was discontinued after one week without documented evidence of ongoing risk assessment or justification. Staff interviews revealed that this resident had managed to exit the building with visitors and had to be redirected frequently due to continued exit-seeking behaviors. However, the resident was not included in the facility's elopement risk binder, and key staff, including the NHA, were unaware of her risk status or previous incidents. Observations and staff interviews indicated a lack of consistent documentation and communication regarding which residents were at risk for elopement and who required supervision during high-risk activities such as smoking breaks. Staff relied on informal knowledge rather than documented lists, and there was insufficient supervision during these times. The facility's failure to identify and supervise residents at risk for elopement resulted in one resident leaving the premises without staff knowledge and another resident's risk not being properly managed or communicated.
Removal Plan
- The facility reviewed and revised the elopement policy.
- The Director of Nursing or designee will complete assessments on all residents to identify their risk for elopement, and care plans will be updated to reflect the residents' current condition, risk for elopement and resident centered interventions.
- A list of residents at risk for elopement will be placed at each nursing station to inform staff of residents at risk.
- The Nursing Home Administrator or Designee will educate all staff, including agency staff, on elopement policies and procedures, documenting residents with exit seeking behaviors, reporting exit seeking behaviors to administration and implementing proper interventions for these residents prior to staff's next scheduled shift.
- The facility will allocate additional staff members to supervise smokers to ensure appropriate supervision is available to meet residents.
- The facility will have one staff member for every eight residents who smoke.
- The Facility will complete a head count of all residents each shift to ensure residents are safe and provided adequate supervision.
- The Director of Nursing of Designee will review progress notes daily to identify any residents with new exit seeking behaviors to ensure appropriate interventions are in place.
- The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for frequency of audits.