Failure to Follow Behavior Management Policy and Resident Rights During Elopement
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's right to a dignified existence and self-determination by not following their behavior management policy and procedures during an elopement incident. The resident, an alert and oriented male with a history of severe bipolar disorder with psychotic features, generalized anxiety disorder, hypertensive heart disease, cannabis use, and nicotine dependence, was assessed as low risk for elopement and had no prior incidents of unauthorized exit. Despite this, the resident left the facility without authorization, and staff attempted to physically intervene to return him to the facility, contrary to the facility's policy emphasizing de-escalation and non-restraint interventions. During the incident, multiple staff members pursued the resident after he exited the building. Accounts from staff and the resident indicate that staff attempted to physically restrain him, with one staff member reportedly grabbing his shirt and another attempting to catch him. The resident described being chased, sitting down voluntarily due to being winded, and then being physically brought to the ground, which he described as being 'slammed.' Hospital records corroborated that the resident sustained a chest wall injury and elevated troponin levels, suspected to be related to minor blunt chest trauma from the incident. Staff interviews revealed confusion and inconsistent adherence to the facility's policy, with some staff attempting to physically intervene and others later being instructed by the clinical director to let the resident go, acknowledging his right to leave. The facility's behavior management policy specifically directs staff to use de-escalation techniques such as verbal redirection, distraction, and active listening, and to avoid physical restraint. In this case, staff actions did not align with these guidelines, as physical intervention was attempted despite the resident being alert, oriented, and expressing a desire not to return. The failure to follow established procedures and respect the resident's rights resulted in a situation where the resident sustained an injury and his dignity and autonomy were not upheld.