Failure to Prevent Elopement of Resident with Known Risk
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement and moderate cognitive impairment was not provided with adequate supervision to prevent elopement. The resident, who had diagnoses including urinary tract infection, difficulty walking, dependence on supplemental oxygen, anxiety disorder, and a PICC line, was assessed as being at risk for elopement upon admission and was equipped with an electronic monitoring device. However, documentation showed inconsistent checks of the device, and staff were not fully aware of the resident's exit-seeking behaviors. On the night of the incident, the resident was last seen at the nurse's station for supervision due to attempts to stand without assistance, but was later assisted to bed and left unsupervised in his room. The resident managed to open his window, remove the screen, and exit the building without being detected by staff. His roommate witnessed the elopement and attempted to alert staff, but there was a delay before staff responded. The resident was missing for several hours before being found by law enforcement in a wooded area on facility property, approximately 75 feet from the building. The resident sustained minor injuries, including scratches and abrasions, but was able to ambulate with limited assistance when found. Interviews with staff revealed gaps in communication and awareness regarding the resident's elopement risk and the proper monitoring of the electronic monitoring device. The DON and Administrator were not fully informed of the resident's prior history of elopement, and staff training on elopement risk identification and response was incomplete at the time of the incident. The facility's policy for missing residents was not fully effective in preventing the resident's elopement or ensuring immediate detection and response.
Removal Plan
- Implemented 1:1 supervision for this resident when he is not in group settings and will remain for this resident for the duration of his stay at the facility. Compliance will be monitored by Department Heads along with the Administrator and Director of Nursing.
- Installed a double lock/window stop system on his patient room window to increase safety. Window lock/stops will be checked for proper operation twice daily for the duration of R2's stay at the facility. The lock/stop system has been installed on all patient room windows and will be monitored quarterly. Compliance will be monitored by the Director of Plant Maintenance.
- Reeducated the staff on the facility's Emergency Procedure for a Missing Resident. Education will continue for all employees quarterly on each shift. Compliance will be monitored by the Department Heads along with the Administrator and Director of Nursing.
- A Quality Assurance Performance Improvement (QAPI) was initiated to ensure that R2 and other facility residents have appropriate supervision and assistive devices in place to prevent accidents, especially those with exit seeking behaviors. Compliance will be monitored by Department Heads along with Administrator and Director of Nursing.