Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to adequately supervise and ensure the safety of a resident who was assessed to be at risk for elopement. The resident, who had severe cognitive impairment, dementia, and a history of exit-seeking behavior, was able to leave the premises without staff knowledge and remained missing for approximately 17 hours. Multiple staff interviews and record reviews confirmed that the resident had been displaying exit-seeking behaviors throughout the morning, including asking staff for directions to a hotel and attempting to exit through various doors. Despite these behaviors and a care plan indicating the need for interventions such as one-to-one supervision as deemed necessary, the resident was not placed on one-to-one supervision at the time of the incident. Staff reported that the resident was difficult to keep track of and was observed wandering throughout the facility, setting off door alarms, and repeatedly asking to leave. Several staff members, including CNAs, LPNs, and social services, noted the resident's confusion and persistent attempts to exit. The resident was last seen by staff in the late morning, and after a search of the facility, it was determined that he was missing. The facility's elopement assessment had previously identified the resident as being at risk, and interventions such as wander guard bracelet checks and reassurance were documented, but these measures were not sufficient to prevent the elopement. Interviews with facility leadership, including the DON and NHA, revealed that there was an expectation for staff to implement additional interventions, such as one-to-one supervision, for residents exhibiting exit-seeking behavior. However, on the day of the incident, these interventions were not implemented, and staff did not escalate the level of supervision despite clear signs of risk. The resident was ultimately found by local police and returned to the facility without significant injury, but the failure to provide adequate supervision and prevent the elopement constituted a serious deficiency.
Removal Plan
- Code 7 was paged overhead indicating missing resident.
- Staff began completing a head count and searching for missing resident inside and outside the facility.
- Administration was notified.
- Police were notified.
- All doors, alarms, and wander guard system were tested, and all functional.
- All wander guards were verified for placement and function.
- A facility wide audit of elopement risks was completed to ensure all residents at risk had been identified and had care plans in place.
- Elopement book was reviewed to ensure all residents at risk had pictures and information in place.
- Facility elopement and missing person policy were reviewed.
- All staff present in the facility were educated on the elopement policy and the missing person policy.
- A plan was put in place to educate every staff member prior to their next working shift.
- Facility confirmed all door alarms and wander guard system were operating properly and were monitored for functionality daily.
- The code to the 600 hall door was changed by the maintenance director.
- A sign was placed on the 600 hall door indicating it was not an exit, and visitors should enter and exit through the main entrance.
- Facility ensured signs were posted to educate visitors on the need to avoid assisting any residents through a door.
- Resident #100 was placed on one to one after returning to the facility until he discharged from the facility.
- Facility ensured elopement drills were conducted daily for 3 days.
- Facility ensured elopement drills were conducted weekly.
- All wander guards were verified for placement and function.
- A facility wide audit of elopement risks was completed to ensure all residents at risk had been identified.
- Facility confirmed all at risk residents had a care plan to address their needs related to their risk of elopement.
- The facility elopement books were reviewed to ensure all at risk residents had pictures and information located in the books.
- The facility policy for elopement and/or exit seeking management and missing person policy were reviewed and deemed appropriate.
- All staff present in the facility were educated on policy, warning signs of elopement, how to identify an at risk resident, what to do if a resident is exit seeking, how to redirect an exit seeking resident, who to notify if a resident is exit seeking, and each staff member was given a laminated check list related to missing resident to attach to their name badge.
- Education of all staff members was completed except for staff members who were on approved leave. The staff members on leave would be educated upon their return to work.
- Facility confirmed all at risk residents had a care plan to address their needs related to their risk of elopement.
- Facility confirmed all door alarms and wander guard system were operating properly and were monitored for functionality daily.
- The code to the 600 hall door was changed by the maintenance director.
- Daily door alarm checks continued.
- A sign was placed on the 600 hall door indicating it was not an exit.
- Facility ensured signs were posted to educate visitors on the need to avoid assisting any residents through a door.
- Resident #100 was placed on one to one until resident discharged from the facility.
- Facility ensured elopement drills were conducted daily for 3 days.
- Facility ensured elopement drills were conducted weekly.
- Elopement policies, procedures, educations, assessments and root cause were reviewed in QAPI.