Failure to Prevent Elopement and Maintain Safe Bedrail Conditions
Penalty
Summary
The facility failed to have an adequate system in place to ensure residents at risk for elopement were properly supervised, resulting in an Immediate Jeopardy situation for one resident. This resident, who had vascular dementia, hemiplegia, cerebrovascular accident, heart failure, and mild cognitive impairment, was assessed as being at risk for elopement upon admission. Despite this, there was no documented evidence of a care plan addressing elopement risk, and staff were not adequately informed of the resident's risk status. The resident exited the building through a window and was found by police pacing on a highway nearly a mile from the facility, before being returned without injury. Staff interviews revealed that CNAs were unaware of the resident's elopement risk and did not notify nursing staff when the resident was missing, assuming he was elsewhere. The DON confirmed that only the day shift nurse was informed of the risk, and no comprehensive communication or care plan was in place for the resident's elopement risk prior to the incident. Additionally, the facility failed to ensure that the environment was free from accident hazards by not properly securing bedrails for three residents. Observations over several days showed that quarter or half bedrails on the beds of these residents were loose and not properly attached. Both the DON and the Director of Maintenance confirmed the bedrails were not secured and required repair. The facility's policy required correct installation and maintenance of bedrails, including following manufacturer instructions and regular inspections, but these procedures were not followed for the affected residents. The deficiencies were identified through observations, record reviews, and staff interviews. The lack of proper communication, documentation, and adherence to facility policies contributed to the failure to prevent elopement and to maintain a safe environment regarding bedrail use. The issues were confirmed by multiple staff members, including the DON, CNAs, and the Director of Maintenance, who acknowledged the lapses in supervision, communication, and equipment maintenance.
Removal Plan
- DON or Designee will screen all new admits or readmits for potential wandering and/or elopement, including history and current cognitive status and continue with ongoing elopement risk assessments.
- Hourly observations for Resident #73 was initiated.
- Hourly observations for all high risk for elopement residents were initiated.
- Ensured all high risk for elopement residents had on orange wristbands.
- Maintenance Director secured all windows.
- DON or Designee will be responsible for updating the elopement binders for all high-risk new admissions and readmissions for elopement. To be placed at each nurses station with face sheets continuously.
- Elopement policy updated to include: any elopement risk resident will wear an orange wrist band as an identifier.
- Charge nurses will meet with all staff (CNAs, nurses, any other direct/indirect care staff) at beginning of each shift to communicate high risk elopement residents.
- DON and ADON inserviced nurses to complete hourly observations of high risk elopement residents and document on monitoring tool – completed inservice.
- DON inserviced MDS nurse to update care plan to reflect elopement risk residents.
- Inservice was completed by DON and ADON to all staff on elopement risk and orange wristbands.
- Education also added to the new hire orientation process.
- DON or Designee will observe and document high risk elopement residents’ behaviors for initial period in facility after new admission or readmission.
- Inserviced staff began using the hourly observations monitoring tool for Resident #73.
- DON or Designee will monitor the completion of the hourly observations of high risk residents and the documentation on monitoring tool is complete.
- Inserviced staff began using the hourly observations monitoring tool for all high risk elopement residents.
- Maintenance Director will monitor windows to random rooms. All findings will be reported to Quality Assurance (QA) committee.
- Hourly monitor tool binder on high risk elopement residents to be completed for the initial period after new admission or readmission.
- DON or Designee will monitor orange wristbands to ensure it is intact and to be changed as needed if soiled or dislodged on high risk residents.
- DON or Designee will complete elopement drills. All findings will be reported to the QA committee.