Failure to Prevent Resident Elopement and Update Care Plan After Exit-Seeking Incident
Penalty
Summary
A deficiency occurred when a resident with cognitive impairment and a history of exit-seeking behaviors was able to leave the facility without staff knowledge. The resident, who had diagnoses including dementia, depression, and anxiety, was observed in multiple progress notes to wander the halls, attempt to follow family members out of the building, and appear lost. Despite these documented behaviors, the resident's care plan was not updated to address wandering or exit-seeking, and no additional elopement risk assessment was completed after an incident where the resident followed a family member out the front door and into the parking lot. Facility policies required that all staff monitor residents with cognitive impairment or exit-seeking behavior, update care plans after incidents, and ensure interventions such as wanderguard devices were in place and checked. However, there was no documentation that a wanderguard was ordered, placed, or checked for functionality prior to or after the incident. Staff interviews revealed confusion about the resident's elopement risk status, lack of awareness of the incident among some staff, and inconsistent knowledge about the use and monitoring of wanderguard devices. The care plan coordinator and DON both acknowledged that the care plan should have been updated, but it was not. Additionally, the facility failed to follow its own policies regarding incident review, documentation, and staff inservicing after the event. The DON and Administrator did not perform a review of the incident or near-miss, and there was no documentation of inservices or written statements about the event. Observations also showed that the wanderguard device, when eventually tested, did not reliably activate the alarm when the resident's wheelchair passed through the front entrance, indicating a failure to ensure the effectiveness of safety interventions.