Failure to Ensure Staff Competency in Managing Elopement and Wandering Behaviors
Penalty
Summary
The facility failed to ensure that licensed nursing staff and nurse aides were trained and competent in managing wandering behavior and elopement, resulting in a resident with severe cognitive impairment eloping and falling from a second-floor window. The resident, who had a history of dementia with behavioral disturbances and previous elopement attempts, was admitted after a psychiatric hospitalization for agitation and elopement behaviors. Despite documented incidents of the resident attempting to open doors and windows, and specific notes of window elopement attempts, the care plan did not include individualized interventions addressing the risk of window elopement, nor were care plan interventions updated after actual elopement attempts. Observations and interviews revealed that the facility's wander guard system was only installed on doors and elevators, not on windows. Multiple staff members, including nurses and CNAs, reported not receiving education or guidance on managing residents at high risk for elopement, particularly those attempting to exit through windows. Several staff were unaware of the resident's specific behaviors and history, and there was no evidence of targeted communication or handoff regarding the resident's risks. Employee records showed that most staff lacked required dementia and elopement training, with new hires missing initial training and long-term staff missing annual competencies. Leadership interviews confirmed that there was no consistent or comprehensive education provided to staff regarding elopement prevention, either at orientation or annually. The Director of Nursing acknowledged not providing on-the-spot education when the resident's behaviors escalated, and the Assistant Director of Nursing was unaware of the gaps in staff training. The Administrator was also unaware that annual education had not been provided, relying on assumptions rather than verification. These failures in staff training, communication, and individualized care planning directly contributed to the resident's elopement and subsequent injury.