Failure to Implement Effective QAPI Plan to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan to prevent elopement among residents identified as at risk. One resident with severe cognitive impairment and a history of wandering was able to exit the facility through a door with an alarm, which was heard by staff after the resident had already left the building. The resident was found ambulating away from the facility and stated an intention to leave. The medical director was not familiar with the resident and did not consider the incident to be an elopement, and there was no indication of heightened concern about resident supervision from leadership at that time. Another resident, also with severe cognitive impairment and multiple medical diagnoses, was able to leave the facility unnoticed, walk a significant distance along high-traffic streets, and was eventually found on an interstate highway by law enforcement. This resident was admitted to a higher level of care for evaluation and treatment of dehydration. Staff interviews revealed that the resident was known to walk throughout the building and sit in the patio area, which was previously left unlocked and unsupervised. On the day of the incident, the resident was last seen in the dining room, and staff searched for an extended period before notifying police. The resident exited through a patio screen door by removing part of the screen, which was later found damaged. Facility policies required regular assessment and supervision of residents at risk for elopement, as well as functioning door alarms and prompt staff response to alarms. However, staff interviews and documentation indicated lapses in supervision, communication, and timely response to a missing resident. The facility's QAPI committee did not have an effective plan in place to prevent these incidents, and there was a lack of clear documentation of a comprehensive QAPI policy at the time of the survey.