Failure to Prevent Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was identified as being at risk for wandering and exit-seeking behaviors. The resident had a history of cognitive impairment, poor decision-making skills, and demonstrated wandering and exit-seeking behaviors, as documented in an Elopement Risk Assessment. Despite these findings, the resident's care plan did not include any interventions to address elopement risk, and there were no physician orders for elopement prevention measures. On the day of the incident, the resident was last seen by staff in a recliner in the community room and later in another resident's room before being returned to his own room around 7:30 p.m. The resident was left unsupervised, and staff failed to monitor the front door, which allowed the resident to exit the facility without detection. The absence of supervision at the front desk was confirmed by video footage, contradicting an initial staff statement. The facility did not document the resident's wandering behaviors in the progress notes, and there was no immediate notification to local authorities by the facility when the resident was discovered missing. The resident was found by police in a nearby residential area without shoes and with no memory of how he arrived there. The police were alerted by a passer-by, not the facility, and the resident was subsequently taken to the emergency department for evaluation. The incident revealed gaps in supervision, documentation, and adherence to elopement prevention protocols, resulting in an immediate jeopardy situation for the resident.
Removal Plan
- Complete a root cause analysis to validate the cause of the resident elopement.
- Complete a head count to ensure all residents are accounted for.
- Reassess the resident upon return from the hospital and implement frequent checks.
- Audit all elopement books to ensure accuracy.
- Review and assess all residents for elopement risk, wandering, and update care plans and orders to include appropriate interventions.
- Assess all residents in house for elopement risk by the Director of Nursing or designee.
- Review and update care plans for residents identified with elopement risks with interventions to prevent elopement by the Director of Nursing or designee.
- Add all residents identified to be elopement risk to Elopement Binder per protocol.
- Conduct a house audit on all doors and exit points to ensure that facility is secure and alarms are functional by Maintenance.
- Conduct education to all facility staff regarding dementia/behavior in LTC residents, elopement risk and mitigation, and elopement policy and procedures to include keeping doors secure.
- Educate all staff on elopement interventions such as responding to alarms, reorienting wandering patients, encouraging activities, monitoring the front lobby and sign in sheet, code 10, and safety checks.
- Educate staff that all residents assessed as an elopement risk will have their picture and face sheet in the elopement book.
- Place elopement books with identified resident photos on all nurses' stations in addition to the current one at the receptionist's desk by the Administrator or designee.
- Screen newly admitted residents for elopement risk on admission, quarterly and as needed, and update care plans appropriately.
- Place new admissions and any resident assessed as an elopement risk in the elopement book that includes photograph and face sheets. Book is available for staff to review and monitor at all times.
- Investigate all incidents, perform root cause analysis and follow up with appropriate interventions by the DON or designee.
- Review elopement interventions and update as required by the QAPI team.
- Ensure the front door is monitored 24 hours 7 days a week by the RN supervisor until the wander guard system is installed.
- Review the lobby monitoring sign in sheet regularly.
- Audit door alarms daily by maintenance.
- Conduct elopement drills monthly on all shifts.
- Monitor the plan of correction by QAPI including all door audits, elopement book, elopement drills and all new admissions will be audited for elopement risk.
- Monitor the plan of correction at the Quality Assurance and Process Improvement meeting until consistent substantial compliance has been met.