Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
A deficiency occurred when a resident with a history of bipolar disorder, depression, anxiety disorder, and memory impairments eloped from the facility. The resident, who was assessed as requiring supervision when walking and had impaired decision-making, was last seen by staff near the entrance. The facility's policy required staff to monitor residents at risk for elopement and to initiate a missing resident action plan if a resident could not be located. On the day of the incident, the resident was able to leave the facility, likely through the front door when it was opened for visitors. The receptionist, responsible for monitoring the entrance, did not observe the resident leaving. Subsequently, both a nurse and an aide noticed the resident was missing from the unit but did not initiate the missing resident action plan as required by facility policy. The facility did not become aware of the resident's absence until approximately 90 minutes later, when local police contacted them after finding the resident about two miles away. The resident was taken to the hospital for evaluation and was found to have no injuries related to the elopement. The failure to provide adequate supervision and to follow established procedures for monitoring and responding to a missing resident resulted in a deficiency and an Immediate Jeopardy situation.
Removal Plan
- The facility conducted a count of all residents to ensure all were accounted for.
- All doors were checked by maintenance and were found to be in good working order.
- All safety devices were checked to ensure they were in place, including electronic devices applied to residents to prevent doors from opening (Wanderguard).
- Resident 1's room was changed from the first floor to the third, and a Wanderguard was placed on the resident. The resident's care plan was updated to include risk for elopement.
- Elopement drills were conducted to ensure that all staff are proficient in the facility's procedure if a resident was missing. Additional future drills were scheduled.
- All residents were audited to ensure they were assessed for risk of elopement, and that care plans were in place for those at risk.
- The facility educated all staff in the facility on the facility's procedure for finding a missing resident. Receptionist staff were educated on their responsibilities to ensure only authorized people leave the building.
- The Director of Nursing or designee was to initiate audits and report results to the QAPI (Quality assurance, performance improvement) committee.
- All staff members were required to be trained on this plan before being permitted back to work.