Failure to Implement Elopement Prevention Protocols and Staff Training
Penalty
Summary
The facility failed to implement appropriate plans of action to correct identified quality deficiencies related to elopement. A resident with a history of metabolic encephalopathy, dementia, impaired safety awareness, and other medical conditions was identified as an elopement risk and was care planned to require an escort and a wander guard when leaving the facility. Despite these interventions, the resident was permitted to sign out of the facility without an escort and exited through the main entrance. The resident removed his wander guard prior to leaving, and staff did not verify its presence or function at the time of the incident. The receptionist and Human Resource Coordinator involved were not fully aware of the elopement risk protocols or the leave of absence (LOA) process, and the receptionist had not received training or participated in drills related to elopement prevention or LOA procedures. Record review revealed that the resident's care plan and physician orders specified the need for a wander guard and supervision when leaving the facility. However, the required elopement assessments were not completed according to policy, and documentation of elopement drills prior to the incident could not be produced. The facility's elopement binder and risk assessments were not consistently updated, and audits of residents at risk for elopement were infrequent, with only three audits documented. Additionally, there was confusion among staff regarding the LOA process, and the receptionist was unaware of the elopement binder and related protocols. Further review of other residents' records indicated inconsistencies in care planning and risk assessment for elopement. For example, one resident was care planned as an elopement risk with a wander guard in place, despite having no documented wandering behaviors or cognitive impairment. Interviews with staff revealed a lack of consistent training and understanding of elopement prevention procedures. The facility's Quality Assurance Performance Improvement (QAPI) program and Performance Improvement Plan (PIP) identified these systemic issues, but the corrective actions outlined were not fully implemented or monitored, contributing to the deficiency.