Failure to Prevent Elopement Due to Inadequate Supervision and Environmental Security
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a documented history of exit-seeking and wandering behaviors was able to elope from the facility without staff knowledge. The resident, who had diagnoses including Alzheimer's disease and unspecified dementia, had repeatedly demonstrated behaviors such as pulling on exit doors, expressing a desire to leave, and making statements about going home. Nursing progress notes documented multiple incidents of the resident attempting to exit the facility, verbalizing intent to break a window, and expressing significant distress and anxiety in the days leading up to the event. On the day of the incident, the resident manipulated a window in a different room on the secure unit, removed the screen, and exited through the window. The facility's monitoring and supervision were insufficient to prevent the resident from leaving undetected. The resident was later found outside the facility by a passerby and brought to city hall, where facility staff retrieved the resident. Upon return, a body audit revealed a small skin tear on the resident's left wrist. The facility's failure to implement an effective monitoring plan and to secure all potential exit points, such as windows, contributed to the resident's ability to elope. Staff interviews and record reviews indicated that while the resident was known to be at high risk for elopement, interventions in place were not adequate to prevent the incident. The deficiency was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents, resulting in a finding of Immediate Jeopardy.
Removal Plan
- Head count of all residents was performed and all other residents were accounted for.
- Resident was returned to the memory care unit and Incident and Accident was completed. Small skin tear on wrist was noted and treated by D.O.N.
- Facility initiated and completed skin audits, elopement risk assessments, and BIMS score on the resident.
- Resident transferred to St. [NAME] Behavioral Health for evaluation and treatment.
- Initiated staff in-service on abuse, neglect and misappropriation, elopement policy and the facility elopement book.
- All residents assessed for elopement risk via elopement/wandering assessment. All residents who are at risk for elopement were noted to be residing in Memory Care Unit of facility. Care plans were updated accordingly.
- All residents' evaluation assessments (BIMS) were updated.
- Elopement book reviewed to ensure all residents at risk for elopement were in the facility’s elopement book with resident picture and demographics.
- All window seals on sliding windows throughout the facility were modified so the windows could not be manipulated to move over the stopper and/or come off track.
- Facility trained all staff on recognizing key factors such as cognitive impairments (e.g., dementia), history of wandering or elopement, through the individualized care plan. Also educated staff on established protocols for preventing elopement, including recognizing early warning signs, managing exit seeking behaviors, and responding to potential incidents.