Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident left the facility undetected through the first floor exit/entrance door and was found several blocks away by local law enforcement. The resident was last seen by staff in the common room in front of the nursing station, and staff became aware of the resident's absence only after being notified by the police. The facility is located in a residential neighborhood with busy cross streets and is close to a shopping plaza. At the time of the incident, the temperature was 88 degrees Fahrenheit. The resident involved was cognitively intact, ambulatory without assistive devices, and required partial assistance to walk 10 feet. The resident had been admitted for therapy and was receiving antipsychotic, antidepressant, and antiplatelet medications. On the day of the incident, the resident was able to leave the facility after being told by a therapist that no therapy sessions were scheduled. The resident then left the premises without staff knowledge and was later found by police, who identified him by his bracelet and contacted the facility. Facility policy required staff to promptly report any resident suspected of being missing and to investigate all incidents. However, staff interviews revealed that the resident was last seen approximately 20-30 minutes before being found outside, and routine checks were performed only every hour to an hour and a half. The incident was documented in the facility's abuse/neglect log, and the resident was assessed upon return, showing no signs of injury or distress. The deficiency was cited for failure to provide adequate supervision and ensure the environment was as free of accident hazards as possible.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. F689 Free of Accident Hazards/Supervision/Devices (a) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 06/17/2025, the Director of Nursing re-educated Staff B, C, and D on the components of this regulation and the facility's Safety and Supervision of Residents & Accidents and Incidents - Investigating and Reporting policies with an emphasis on adequate supervision and safety. (b) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On 04/05/2025, a Quality Review audit was completed on all residents, no new residents were identified as at risk for elopement. All residents already identified at risk for elopement were checked for wander guard placement and proper functioning. By 06/25/2025, all current residents were re-evaluated for changes in conditions or risk factors that may pose a risk for a potential accident. Any issues or concerns were immediately addressed, interventions and care plans revised, as needed. No further discrepancies were observed. All new residents will be assessed for potential accidents upon admission. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By 04/05/2025, the Director of Nursing/designee reviewed and updated elopement binders; ensured binders were current and placed at each nursing station, therapy department, activity department, kitchen, & front desk. Elopement binders were updated when necessary. By 04/05/2025, the Maintenance Director/designee checked all exit doors for proper functioning to include transponder for wander guard system. Daily audits of doors for proper functioning were completed for three days, followed by weekly audits. On 04/05/2025, the Clinical Educator/designee initiated education of all staff on the facility's Elopement standard and guidelines, ANEMMI with an emphasis on Neglect, Alarm Response, and Wander Guard placement and functioning. Newly hired staff will receive this education during orientation. Education continues monthly. On 04/05/2025, the Clinical Educator/designee initiated elopement drills for all staff participation. Drills will be completed on each shift, then move to monthly rotating each shift. On 04/05/2025, a single point of entry was set up at the front doors in the reception area. The front doors were set to remain locked at all times. To gain access, any non-employee will need to ring the doorbell for entry. Once inside, every non-employee must sign in into the visitor's log. Everyone leaving the building must do so from the front door and be let out by the receptionist or be escorted out by a staff member with a fob. Single point of entry and these entry and exit procedures continue to be in place. By 06/25/2025, all current residents were re-evaluated for changes in conditions or risk factors that may pose a risk for a potential accident. Any issues or concerns were immediately addressed, interventions and care plans revised, as needed. No further discrepancies were observed. All new residents will be assessed for potential accidents upon admission. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Administrator/designee will conduct a weekly Quality Review audit of residents for 4 weeks, then every 2 weeks for 2 months to ensure compliance that supervision is adequate and interventions are appropriate, when necessary. Findings will be reported at the monthly QA/Risk Management meeting. These Quality Reviews will be reported until the committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Regional Director of Clinical Operations/designee when completing their Quality Systems Review to maintain compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. N110 FAC Physical Environment-Safe, Clean, Homelike (a) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 06/17/2025, the Director of Nursing re-educated Staff B, C, and D on the components of this regulation and the facility's Safety and Supervision of Residents & Accidents and Incidents Investigating and Reporting policies with an emphasis on adequate supervision and safety. (b) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On 04/05/2025, a Quality Review audit was completed on all residents, no new residents were identified as at risk for elopement. By 06/25/2025, all current residents were re-evaluated for changes in conditions or risk factors that may pose a risk for a potential accident. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. F689 Free of Accident Hazards/Supervision/Devices (a) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 06/17/2025, the Director of Nursing re-educated Staff B, C, and D on the components of this regulation and the facility's Safety and Supervision of Residents & Accidents and Incidents - Investigating and Reporting policies with an emphasis on adequate supervision and safety. (b) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On 04/05/2025, a Quality Review audit was completed on all residents, no new residents were identified as at risk for elopement. All residents already identified at risk for elopement were checked for wander guard placement and proper functioning. By 06/25/2025, all current residents were re-evaluated for changes in conditions or risk factors that may pose a risk for a potential accident. Any issues or concerns were immediately addressed, interventions and care plans revised, as needed. No further discrepancies were observed. All new residents will be assessed for potential accidents upon admission. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By 04/05/2025, the Director of Nursing/designee reviewed and updated elopement binders; ensured binders were current and placed at each nursing station, therapy department, activity department, kitchen, & front desk. Elopement binders were updated when necessary. By 04/05/2025, the Maintenance Director/designee checked all exit doors for proper functioning to include transponder for wander guard system. Daily audits of doors for proper functioning were completed for three days, followed by weekly audits. On 04/05/2025, the Clinical Educator/designee initiated education of all staff on the facility's Elopement standard and guidelines, ANEMMI with an emphasis on Neglect, Alarm Response, and Wander Guard placement and functioning. Newly hired staff will receive this education during orientation. Education continues monthly. On 04/05/2025, the Clinical Educator/designee initiated elopement drills for all staff participation. Drills will be completed on each shift, then move to monthly rotating each shift. On 04/05/2025, a single point of entry was set up at the front doors in the reception area. The front doors were set to remain locked at all times. To gain access, any non-employee will need to ring the doorbell for entry. Once inside, every non-employee must sign in into the visitor's log. Everyone leaving the building must do so from the front door and be let out by the receptionist or be escorted out by a staff member with a fob. Single point of entry and these entry and exit procedures continue to be in place. By 06/25/2025, all current residents were re-evaluated for changes in conditions or risk factors that may pose a risk for a potential accident. Any issues or concerns were immediately addressed, interventions and care plans revised, as needed. No further discrepancies were observed. All new residents will be assessed for potential accidents upon admission. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Administrator/designee will conduct a weekly Quality Review audit of residents for 4 weeks, then every 2 weeks for 2 months to ensure compliance that supervision is adequate and interventions are appropriate, when necessary. Findings will be reported at the monthly QA/Risk Management meeting. These Quality Reviews will be reported until the committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Regional Director of Clinical Operations/designee when completing their Quality Systems Review to maintain compliance.