Failure to Prevent Elopement of Resident with Exit-Seeking Behaviors
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for a resident with a known history of exit-seeking and elopement behaviors. The resident, who had diagnoses including anxiety, depression, unspecified psychosis, schizophrenia, and pedophilia, was assessed as having moderately impaired cognitive skills and required supervision for mobility and transfers. Despite a care plan identifying the resident as at risk for elopement and documenting previous incidents of exit-seeking, interventions such as personal safety alarms or devices were not implemented. The resident had previously exhibited exit-seeking behaviors, including climbing over a courtyard wall when frightened by EMTs and moving furniture to facilitate escape attempts. On the evening of the incident, the resident climbed a gazebo in the facility's walled courtyard, jumped over the 66-inch wall, and left the property. The event occurred while the nurse was occupied assisting EMS with another resident, leaving the at-risk resident unsupervised. The resident was located approximately 0.6 miles from the facility, hiding behind an air conditioning unit near a busy intersection, and attempted to flee from law enforcement before being apprehended. The facility's records and staff interviews confirmed that the resident had previously used the same method to attempt elopement and that staff were aware of the resident's behaviors and triggers, such as being frightened by EMS presence. The facility's policy required that residents identified as at risk for wandering or elopement have care plans with appropriate interventions to maintain safety. However, the resident's care plan and supervision were not updated in response to repeated exit-seeking behaviors and prior incidents. Staff interviews indicated that elopement risk assessments and care plan updates were not consistently performed when the resident exhibited increased exit-seeking behavior, contributing to the failure to prevent the elopement event.
Removal Plan
- Completed audits of clinical records for residents at risk for exit-seeking behavior or elopement.
- Removed the Gazebo from the courtyard.
- Removed a tree in the courtyard.
- Secured patio furniture.
- Equipped all exit doors with Wander-guard key pad.
- Provided in-service training to staff on the elopement exit seeking policy.
- Monitoring changes in residents' behavior.