Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards, resulting in two residents eloping from the premises. One resident with dementia, severe cognitive impairment, and a history of exit-seeking behaviors was not properly assessed for elopement risk initially, and their care plan was not updated in response to repeated exit-seeking incidents. The resident repeatedly removed their electronic monitoring device, and staff failed to ensure the device was in place and functioning. Documentation showed that the device was not checked on several occasions, and when the resident was found attempting to exit the building, the wander guard was not on their person. Additionally, the facility's monitoring systems, such as the wander guard system on elevators, were not consistently checked or functioning, as evidenced by maintenance records and staff interviews. Another resident with paranoid schizophrenia and moderate cognitive impairment was also identified as an elopement risk and had a history of wandering. Despite being ordered to wear an electronic monitoring device, the resident was able to leave the facility undetected. Staff and witness statements indicated that the wander guard system did not alarm when the resident exited via the elevator, and the resident was later found outside the facility with injuries after a fall. Staff interviews revealed gaps in supervision and a lack of recognition when residents at risk for elopement left the premises. The facility's elopement risk assessment tool was found to be inadequate, lacking a comprehensive scoring system, and staff were not consistently reeducated on elopement prevention following incidents. There were also failures in updating individualized care plans and implementing new interventions after repeated elopement attempts. The combination of insufficient monitoring, lack of timely care plan updates, and failure to ensure the functionality of safety devices contributed to the residents' ability to elope, creating an immediate jeopardy situation.
Removal Plan
- The Facility is obligated to provide adequate supervision which does not rely on the Wander guard System and is based on the individual resident's assessed needs and the risks identified in the Exit Seeking Elopement Evaluation/ Wandering Tool, which does not replace an electronic monitoring device.
- Review and revise the elopement evaluation/wandering assessment to include comprehensive scoring system.
- Current residents in-house will be reassessed for exit seeking / elopement by the Director of Nursing/designee.
- Residents will be assessed for exit seeking/elopement by the admitting RN upon admission.
- Elopement binder will be revised upon completion of all assessments by the Director of Nursing/designee.
- Per results of assessments, care plans will be updated and implemented with resident-specific interventions by Director of Nursing/designee as warranted.
- Elopement policies will be reviewed and revised as necessary by Nursing Home Administrator/designee.
- Wander guard system will continue to be audited by Environmental Director/designee.
- Education of all facility staff will be conducted by Director of Nursing/designee on Elopement Risk and Supervision of residents.
- QA/QAPI will be conducted related to plan of correction for F689. Meetings will be conducted regularly.