Failure to Prevent Elopement Due to Inadequate Assessment, Monitoring, and Environmental Controls
Penalty
Summary
The facility failed to ensure that a resident with a known history of elopement was properly assessed and monitored to prevent elopement. The resident, who had diagnoses including mild cognitive impairment, chronic kidney disease, congestive heart failure, and a history of elopement from a previous assisted living facility, was admitted without adequate recognition of their elopement risk. Despite prior incidents, such as the resident packing belongings and attempting to leave the locked memory care unit, staff did not update the resident’s elopement risk status or implement appropriate interventions. The resident was able to remove window lock hardware, tie bed sheets together, and exit from a second-floor window undetected, ultimately being found days later approximately ten miles away, disoriented and with physical evidence of being outdoors for an extended period. The facility also failed to identify and assess other residents who exhibited exit-seeking or elopement behaviors. Several residents with cognitive impairments and histories of wandering or elopement were not reassessed after incidents of attempting to exit the locked unit. Staff interviews revealed that some residents repeatedly tried to leave the unit, but these behaviors were not consistently reported, reassessed, or documented in the elopement risk binder. Additionally, the facility did not maintain an accurate and current list of residents at risk for elopement at the front desk as required by policy, and some residents with documented risk were not included in the binder or on the list provided by nursing leadership. Environmental safety measures were also lacking. Exit doors and windows were not consistently secured or monitored, and staff did not respond promptly or effectively to door alarms. On one occasion, a staff member left an external door propped open and unattended while the alarm sounded, and no immediate search or head count was conducted to ensure resident safety. Maintenance staff were not informed of missing or tampered window locks, and there was no consistent process for verifying the integrity of security measures. These failures contributed to the facility’s inability to prevent or promptly respond to elopement incidents.
Removal Plan
- Residents R2 - R9 were reassessed for elopement risk by Social Services and DON; interventions were added to care plans.
- All exit doors and windows were checked and secured by Maintenance; window hardware was replaced or reinforced with tamper-proof locks.
- Resident head counts and census verification were conducted by Charge Nurse and DON; all residents were confirmed present.
- Elopement risk list was updated and placed at front reception and nurse's stations.
- All staff were in-serviced on elopement protocol, alarm response, and head-count procedure.
- Facility-wide audit was completed by the DON to identify any residents exhibiting exit-seeking behaviors.
- Environmental rounds will be completed to confirm window locks and alarm integrity by Administrator, Maintenance Director, or Maintenance assistant.
- Reception desk binder will be updated with a list of elopement-risk residents.
- Alarm response protocol: immediate head count and documentation is required after response to door alarms with no identifiable cause.
- Nurses and Social Services were trained on how to accurately complete the elopement assessment by outside Social Services Consulting group.
- Initial Elopement Risk Assessment will be completed by nursing, and assessments by social services reviewed and supervised by Social Services Consulting completed upon admission, quarterly, significant change, or any observed exit-seeking behavior.
- Staff training will be integrated into new-hire orientation and annual in-services; includes training for elopement vs wandering risk and interventions.
- Elopement binder will be updated by social service consultant based on results of elopement risk assessment.
- Binder reviewed by Administrator/DON.
- Facility to complete elopement drills for all shift by Social Services consultant, Administrator and DON.
- Results of drills to be reviewed Administrator/DON.
- QA Committee to audit elopement-risk residents for compliance with interventions and monitoring.
- DON/Social Services Consultant to review all elopement risk assessments completed and report findings in QAPI.
- Maintenance to conduct door alarm and window lock checks and log results.