Failure to Prevent Elopement and Maintain Safe Evacuation Routes
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, specifically in the case of a resident with a high risk for elopement. The resident, who had a history of impulsive behaviors, cognitive impairment, and multiple medical conditions including bipolar disorder, chronic heart failure, and a traumatic brain injury, was admitted to the secured unit after being assessed as high risk for elopement. Despite the resident's repeated exit-seeking behaviors, verbalizations of wanting to leave, and documented behavioral episodes such as refusing care, throwing food, and expressing distress, the facility did not implement or follow individualized interventions for supervision and monitoring as outlined in the care plan. On the day of the incident, the resident exhibited escalating agitation, refused his meal, and attempted to contact family without success. Staff failed to provide increased oversight or frequent checks during this period, and the resident was left unmonitored for approximately four hours before being discovered missing. The facility's investigation revealed that the resident eloped by overriding the window safety mechanism and climbing over a gate in the secured courtyard. The absence of consistent monitoring and failure to respond to the resident's behavioral cues resulted in the resident being missing for approximately 46 hours before being located at a homeless shelter. Documentation and staff interviews confirmed that the care plan lacked specific interventions to address the risk of elopement and that staff did not consistently implement the existing interventions. The facility's records also showed a pattern of the resident expressing a desire to leave, refusing medications, and exhibiting aggressive or impulsive behaviors, yet these were not met with appropriate or timely interventions to ensure his safety. Additionally, the facility did not have an effective evacuation plan in place. Observations showed that evacuation routes were not clearly posted, and the primary emergency egress for the secured unit was padlocked, with staff unaware of the key's location. Staff interviews indicated a lack of training and understanding of evacuation procedures, and the physical barrier of the padlocked gate prevented accessible egress in an emergency. These failures created a hazardous environment for all residents, as staff were not prepared to safely evacuate residents in the event of an emergency, and the environment was not adequately maintained to prevent accidents or ensure resident safety.
Removal Plan
- The padlock and the latch on the outdoor fenced storage areas were removed by the NHA.
- The facility map of the egress routes were posted by the life safety/maintenance resource for all halls.
- The facility was toured by the life safety resource to identify and ensure all egress exits were unlocked and accessible.
- All residents were reviewed by the director of nursing (DON) and clinical resource for elopement risk and care plans were updated as needed.
- Education with the NHA and the IDT (interdisciplinary team) initiated by clinical resource on keeping facility egress routes unlocked and accessible.
- All staff education initiated by DON/designee on specific evacuation routes, keeping egress exit for emergency exits for the secured unit unlocked and accessible, the codes for the exit doors and the facility evacuation map postings.
- Education on the emergency operations procedure quick reference guide initiated which showed initial employee expectations and responsibilities.
- Window security devices will continue to be monitored until window alarms are in place.
- Window alarm installation to be initiated for the secured unit.
- All staff were to be educated on evacuation procedures during orientation.
- Staff education initiated by the DON/designee on the need for safety checks and monitoring during a behavioral episode to prevent further occurrences and where to locate resident elopement care plans.
- Staff were educated that although residents may request to be left alone or to have their door closed, it does not eliminate the facility's obligation to ensure the safety of the resident; staff needs to verify that the resident was safe and present.
- Increased monitoring will be completed on a case by case basis dependent upon situation and if warranted the resident will be placed on 15-minute checks.
- Behavioral episodes could include verbal outbursts, physical aggression, increased exit-seeking behaviors, tearfulness, statements about leaving/going home and pacing.
- The facility will be completing a headcount on the secured unit every two hours by floor nurse, nursing management, or designee.
- Headcount to be completed on paper audit form for a minimum of 12 weeks or until substantial compliance has been achieved.
- The DON, or designee, will complete random audits three times per week for 12 consecutive weeks.
- The audit will include: Staff interview: Does staff member know evacuation route? Observation: All egress routes are unlocked and available in case of emergency? Staff interview: Does staff know to provide safety checks and increased monitoring during a resident behavioral episode? Increased monitoring will be completed on a case by case basis dependent upon situation and if warranted the resident will be placed on 15-minute checks. Behavioral episodes can include verbal outbursts, physical aggression, increased exit-seeking behaviors, tearfulness, statements about leaving/going home and pacing. Staff interview: Does staff know how to access the resident's elopement care plan? Staff interview: Does staff know the codes to the exit doors? Additional comments and/or interventions if issues noted on audit form.
- Audit records will be reviewed by the risk management/quality assurance committee monthly until such time consistent substantial compliance has been achieved as determined by the committee.