Failure to Implement Elopement Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement, severe cognitive impairment due to Alzheimer's disease, and significant visual impairment was able to leave the facility undetected. The resident had previously demonstrated exit-seeking behaviors, including playing with door codes, expressing a desire to leave, and having a documented high elopement risk score. Despite these clear risk factors, the facility failed to implement appropriate interventions or update the resident's care plan to address elopement risk, even after prior incidents where the resident exited the facility and was returned. The facility's own policies required that residents identified as at risk for elopement have these issues addressed in their individual care plans. However, after multiple incidents where the resident left or attempted to leave the facility, there was no investigation, incident report, or care plan developed to mitigate the risk. The resident was also moved out of the memory care unit without documented justification, despite meeting the criteria for continued placement in that secure environment. Staff interviews confirmed that no care planning or interventions were put in place after previous elopement attempts, and the resident's risk was not reassessed or addressed in the care plan. On the day of the incident, the resident exited the facility by following a visitor through a door, walked outside the premises, and was later found at a fast-food restaurant over a mile away after being missing for approximately two hours. The resident's family and staff had previously expressed concerns about his desire to leave and his increased agitation following his wife's death. The lack of timely and appropriate interventions, failure to follow facility policy, and absence of a care plan addressing elopement risk directly led to the resident's undetected exit and the resulting immediate jeopardy situation.
Removal Plan
- R #1 is residing in the Memory Care Neighborhood, a secured unit.
- R #1 Elopement Assessment has been updated, and a care plan has been developed with appropriate interventions.
- All residents have an Elopement Assessment and were audited to ensure that if they have a score higher than 10, they have a care plan in place with appropriate interventions.
- All staff have reviewed and signed a copy of the Facility Elopement Policy.
- The Director of Nursing, or designee, will audit all new admissions for elopement risk and ensure appropriate interventions are in place.
- The Director of Nursing, or designee, will audit residents, based on MDS schedule, to ensure Elopement Assessment is completed and appropriate interventions are in place.
- The Director of Nursing was educated to review Elopement Assessments to ensure that proper care plan interventions are in place, based on the MDS schedule and admissions.
- The Northeast door code has been changed and only staff are allowed to have this code.
- All visitors and staff must enter and exit the facility through the front lobby only.
- All DPOA's and Emergency contacts will be contacted to let them know of the change.
- Signage will be posted.
- Staff education has been sent regarding these changes and to ensure they do not give out the code to the Northeast door and that they all use the front lobby to enter and exit.
- If staff hear the alarm go off, they need to remind the visitor to use the front lobby door, or if they cannot identify who set the alarm off, they need to call a code missing person and start a headcount.
- All physician orders and physician progress notes have been reviewed for R #1 and have been placed.
- Resident is utilizing nonpharmacological interventions, residing in the memory care unit, and on antidepressant medications, per Behavioral Care Solutions recommendations.