Failure to Provide Adequate Supervision Resulting in Resident Elopement
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, who was cognitively intact but required partial assistance to walk and was receiving antipsychotic, antidepressant, and antiplatelet medications, had been admitted to the facility less than a month prior. On the day of the incident, the resident was last seen by staff in the common room in front of the nursing station and was later reported missing. The facility is located in a residential neighborhood with busy cross streets and a nearby shopping plaza, increasing the risk associated with unsupervised elopement. Facility policy required staff to promptly report and investigate all cases of missing residents, and to attempt to prevent departures in a courteous manner. However, staff interviews revealed that the resident was not observed for a period of approximately 20-30 minutes before being found by police. The resident was able to provide personal information to law enforcement, who contacted the facility and returned the resident. Documentation indicated that the resident was alert, oriented, and in good physical and emotional condition upon return, with no injuries or distress noted. The incident was recorded in the facility's abuse/neglect log and incident notes, and the resident's care plan was updated after the event to reflect the risk for elopement. Prior to the incident, there were no alarms or wander alert devices in use for this resident, and the care plan did not include specific interventions for elopement risk. The deficiency was cited under state and federal regulations requiring the facility to maintain a safe and secure environment and to provide adequate supervision to prevent such incidents.
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. 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. 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, 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 updated when necessary. By 04/05/2025, Maintenance Director/designee checked all exil doors for proper functioning to include transponder for wander guard system. Daily audit of doors for proper functioning completed for three days, followed by weekly audits. On 04/05/2025, 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, 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 fog. 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. On 04/05/2025, Administrator/designee initiated QAPI Plan with interdisciplinary Team, including Medical Director, participation on safety with a focus on elopement. Reviewed during QA Meeting on 04/08/2025. On 04/07/2025, Director of Nursing/designee began daily clinical review of new admissions/re-admissions and change in condition that may require increased supervision and/or risk for elopement evaluation. Admission and re-admission reviews continue during daily clinical meetings (Monday through Friday). On 04/07/2025, Maintenance Director/designee placed a Red Box/ Exit Door Alarm on every exit door to notify personnel of any unauthorized entry/exit attempts on emergency exit doors. By 07/16/2025, all employees will be re-educated by the Clinical educator/designee 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. Newly hired employees will receive education during orientation. (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, and 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.