Failure to Prevent Resident Elopement Due to Inadequate Supervision and Delayed Response
Penalty
Summary
Maple Heights Health and Rehab was found noncompliant with federal and state regulations after a complaint survey revealed that the facility failed to maintain an environment free of accident hazards for one resident. The facility's elopement policy required staff to conduct a head count and announce a code green if a resident was missing, with subsequent notifications to administration, the DON, and the attending physician, and to contact emergency responders if the resident was not found in a reasonable time. Despite these procedures, a resident with a recent history of hospital admission, housing instability, and substance use was able to leave the facility undetected. On the day of the incident, the resident was last seen by a nurse aide around noon. At 2:30 p.m., staff noticed the resident's lunch tray was untouched and that he had not been seen for over two hours. A search was initiated, and it was discovered that the receptionist had seen the resident leave the building at 12:30 p.m., mistaking him for an employee. The code green protocol was not activated until after this discovery, and the local police were notified. The resident was eventually found several miles away and taken to the hospital for evaluation. Interviews with staff revealed delays in recognizing the resident's absence and in activating the facility's elopement protocol. The administrator stated that the resident left against medical advice and did not consider it an elopement. However, the sequence of events and staff interviews indicated that the required supervision and timely response to a missing resident were not provided, resulting in the resident's unsupervised departure from the facility.
Plan Of Correction
Preparation and submission of this Plan of Correction is required by state and federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding. Resident R2 no longer resides in the facility. To identify residents who have the potential to be affected, a review of resident elopement risk evaluations done in the last quarter will be conducted to ensure those at risk for elopement have appropriate interventions. To prevent recurrence, nursing staff was educated on the elopement policy and licensed nurses were educated on the Against Medical Advice discharge policy at the time of the event by the Director of Nursing/designee. To monitor and maintain compliance, the Director of Nursing/designee will audit 5 residents at risk of exit seeking to ensure interventions are in place weekly x 4 weeks and monthly x 2 months. Results of the audits will be forwarded to the center Quality Assurance Performance Improvement committee for review and recommendations.