Failure to Prevent Elopement and Ensure Smoking Safety
Penalty
Summary
The facility failed to implement sufficient monitoring interventions and supervision to prevent an elopement incident involving a resident. The resident, who had a history of traumatic subdural hemorrhage, mild cognitive impairment, COPD, type 2 diabetes, repeated falls, anxiety, depression, and nicotine dependence, was able to exit the facility without staff awareness. The resident left the premises by unlocking the door and leaving the property to purchase cigarettes, despite the facility's status as a tobacco-free, non-smoking environment. Staff interviews and documentation confirmed that the resident was able to access the door release button and leave the facility unsupervised. Prior to the elopement, there was no evidence that the facility had conducted a safe smoking assessment or implemented any safety interventions related to the resident's smoking habits. Progress notes indicated that the resident had previously been caught smoking inside the facility and had expressed frustration about not being able to smoke, but no additional safety measures or care plan updates were documented. The resident's care plan and progress notes lacked any interventions or updates addressing elopement risk or smoking safety from the time of the incident until the investigation several days later. Staff interviews revealed that the resident's cigarettes and lighter were kept in a locked medication cart, and when the resident requested a cigarette, staff would provide them and allow the resident to smoke on the porch. However, there was no supervision or monitoring in place to prevent the resident from leaving the property. The facility was unable to provide a smoking policy when requested, and there was no documentation of the elopement in the progress notes until the investigation began. At the time of the investigation, no elopement prevention interventions had been implemented for the resident.
Removal Plan
- Resident will have a smoking assessment completed. Resident will have supervised smoking three times per day until discharged to a smoking facility, or until discharged to his residence.
- All residents will be assessed for elopement risk by the director of nursing or designee.
- All care plans for residents identified with elopement risks will be reviewed and updated if needed with interventions to prevent elopement by the Director of Nursing or designee.
- A facility care feed message will be sent to families reminding them that the facility is a non-smoking facility and resident smoking is prohibited.
- Education will be completed by all staff on elopement risks, assessments, and supervision of residents by the director of nursing or designee.
- Education will be provided to all staff on facility smoking policy. Facility is a non-smoking facility for residents.
- Elopement books with identified resident photos will be placed on all nurses stations in addition to the current one at the receptionist's desk by the Administrator or designee.
- A protective device will be placed over the exit door button to prevent residents from access.
- Audits will be implemented to ensure residents are adhering to the facility smoking policy by the Director of nursing or designee.
- New admissions will be audited for elopement and smoking risks at morning stand up meeting by the director of nursing or designee to ensure appropriate interventions are in place as needed.
- An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator or designee.
- This part of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met.