Failure to Provide Elopement Prevention Training to Staff
Penalty
Summary
The facility failed to provide required training on resident elopement prevention for all new and existing staff members, as evidenced by a review of employee files for eight sampled staff members, including Certified Nursing Assistants and a Restorative Nursing Assistant. There was no documented evidence that these employees received training related to resident elopement, despite the facility's own assessment indicating that such training was necessary for staff to provide appropriate care and support for residents at risk of elopement or wandering. As a result of this lack of training, two residents were able to move from a locked area into the facility's lobby and subsequently exit through the front door without supervision or authorization. Interviews with the Director of Staff Development revealed that while new hire training included a response protocol for missing residents (Code Black), it did not cover preventive interventions or how to distinguish residents from visitors. The Director of Nursing believed that elopement training was ongoing, but there was no evidence to support this, and staff had not received the required education upon hire or annually.