Failure to Prevent Elopement Due to Lapses in Supervision, Communication, and Alarm System Functionality
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known risk for elopement exited the facility unsupervised through the main front door. The resident, who had diagnoses including dementia, memory deficit, cerebral infarction, atrial fibrillation, and diabetes, was found by police approximately half a mile away on a busy six-lane roadway after sunset. Facility staff were unaware that the resident had left the premises, and the resident was unable to communicate her address or destination to the police. The facility's policy required systematic monitoring and management of residents at risk for elopement, including timely response to alarms and implementation of care plan interventions, but these measures were not effectively executed. Interviews and record reviews revealed multiple lapses in supervision and communication. Staff members assigned to the resident did not know she was at risk for elopement, and no alarm or beeping sound was heard at the nurse's stations at the time of the incident. The care plan for the resident was not updated to reflect her elopement risk, and there were no interventions documented to address her behaviors of seeking to communicate with family or pacing near exit doors. Additionally, staff failed to redirect the resident or provide additional supervision when she expressed agitation and a desire to contact her daughter earlier in the day. Technical failures also contributed to the deficiency. The main lobby door's alarm system was not functioning as intended: the annunciator device on one wing was muted, and the other wing's device did not have a designated alarm switch for the main lobby door. Reception staff, who were responsible for monitoring the elopement risk binder and door alarms, were not aware of the resident's risk status. The front doors were left unattended and unlocked for a period in the evening, further compromising resident safety. These combined failures in supervision, communication, care planning, and alarm system functionality led to the resident's unsupervised exit and subsequent elopement.
Removal Plan
- Resident #1 returned to facility, placed on one-on-one supervision. Evaluation by LPN revealed no signs of injury or distress. Care Plan updated to reflect current care needs. A head count was conducted of current residents at the facility by RN supervisor. No concerns were identified.
- Current facility residents had elopement risk screens completed. Two additional residents triggered at risk for elopement. Orders and Care Plan were updated to reflect current needs based on updated Elopement Risk Evaluations.
- Elopement risk binders were reviewed to ensure they contain photos and demographic information of residents evaluated to be at risk for elopement. The surveyors reviewed and verified the 3 elopement binders located at the Receptionist desk, C Wing nurse's station and B Wing nurse's station were accurate.
- Elopement Drills to include door alarm drills conducted each shift. Education on elopement process, exit seeking behaviors and exit seeking behavior process/procedures discussed after each drill.
- Education for current staff initiated related to the facility Elopement/ Wandering Residents policy, Abuse, Neglect, Misappropriation and Exploitation, elopement/exit seeking behaviors identification, staff notification of elopement risk, location and contents of elopement risk binders, initiating enhanced supervision for residents actively exit seeking, responding to door alarms and proper actions to take once determined to be exit seeking or at risk for elopement. It also included the change to entry and exit of the facility through designated doors. Licensed nurses received specific education on exit seeking behavior and initiating appropriate care plan, orders and adding the elopement risk alert to the gray bar (this is in the electronic medical record and shows immediately below the picture of the resident in both the nurses charting system and the CNA charting system), immediately updating the elopement risk binders, creating a new elopement risk assessment in the computer and notifying nursing management. Receptionist received specific education followed by specific competencies on monitoring the door alarm system and notification to maintenance if a failure is identified, understanding the importance of the elopement binder and reviewing it at the beginning of each shift worked, and the proper procedures of resident LOA, signature for each oncoming and off-going shift on the clipboard indicating they had both appropriately initiated or deactivated the screamer alarm and for their review of the elopement binder, the process of utilizing the video doorbell for visitor/vendor entry and exit and notification of nursing manager if exit seeking behavior is identified.
- Education was conducted with IDT team on the process of identification, care planning, prevention, and response of elopement/exit seeking behaviors in morning meeting by progress/behavior note review and a review of the elopement risk UDAs, admission and readmission assessments (that contain the elopement risk evaluation for new residents) completed.
- Huddles are conducted at the beginning of each shift to discuss elopement risk and fall risk residents. This is an added communication to ensure staff are aware of at-risk residents.
- Door function and alarms were checked by the Administrator and the Maintenance Director, all doors and alarms were functioning appropriately. During the review by Maintenance Director, the C wing annunciator was noted to be muted. The volume of the annunciator was increased, and the button was disabled to remove the ability of staff to adjust the volume by vendor.
- Education provided by Staff Development Coordinator, DON and Administrator. All facility staff received education on the facility elopement/ Wandering Residents policy, Abuse, Neglect, Misappropriation and Exploitation, elopement/exit seeking behaviors identification, staff notification of elopement risk, location and contents of elopement risk binders, initiating enhanced supervision for residents actively exit seeking, responding to door alarms and proper actions to take once determined to be exit seeking or at risk for elopement. It also included the change to entry and exit of the facility through designated doors. All licensed nurses received education on exit seeking behavior and initiating appropriate care plan, orders and adding the elopement risk alert to the gray bar (this is in the electronic medical record and shows immediately below the picture of the resident in both the nurses charting system and the CNA charting system), immediately updating the elopement risk binders, creating a new elopement risk UDA and notifying nursing management. All receptionists have been educated on monitoring the door alarm system and notification to maintenance if a failure is identified, understanding the importance of the elopement binder and reviewing it at the beginning of each shift worked, and the proper procedures of resident LOA, signature for each oncoming and off-going shift on the clipboard indicating they had both appropriately initiated or deactivated the screamer alarm and for their review of the elopement binder, the process of utilizing the video doorbell for visitor/vendor entry and exit and notification of nursing manager if exit seeking behavior is identified.
- Newly hired staff and staff members on leave will receive education at orientation or prior to working their next scheduled shift.
- Root Cause Analysis (RCA) completed and reviewed by QAPI. Additional contributing root causes were identified and addressed in QAPI, as outlined below. These factors were staff response, staff knowledge of elopement risks and resident safety, appropriate plan of care/interventions for residents, muting of the C wing annunciator.
- The facility conducted an ad hoc QAPI meeting which included the Facility Administrator, DON, Medical Director via telephone, and additional staff members. The Performance Improvement Plan was accepted by the committee. The annunciator and the correction plan of the annunciator was reviewed in QAPI as indicated by the review of the maintenance enhancement plan. Door alarm annunciator volume increased on C wing, mute button on C wing annunciator disabled. Reviewed staff education completed including identification and response/process of exit seeking behaviors, elopement drills conducted. No additional recommendations were made at that time.