Failure to Implement Elopement Prevention Measures for At-Risk Resident
Penalty
Summary
A resident with diagnoses including Alzheimer's Disease, Dementia with Mood Disturbance, and Major Depressive Disorder was admitted to the facility and assessed as being at risk for elopement. The resident was cognitively moderately impaired, independently ambulatory, and had recently returned from inpatient psychiatric treatment. An elopement risk assessment completed upon reentry indicated a high risk for wandering and exit-seeking behaviors, with documentation noting the resident verbalized a desire to leave the facility and scored above the threshold for elopement risk. Despite the identified risk, the resident did not have a personal alarming device in place, which was an intervention indicated for residents at risk of elopement. On the day of the incident, staff were unaware that the resident had left the facility until a CNA arriving for her shift observed the resident walking down a rural road. The CNA recognized the resident, engaged her, and transported her back to the facility, at which point other staff members assisted in escorting the resident inside. Multiple staff interviews confirmed that the resident was last seen at the nurse's station shortly before being found outside and that the required alarming device was not in use at the time of the incident. The failure to implement the necessary safety intervention for a resident known to be at risk for elopement resulted in the resident leaving the facility without staff knowledge. The absence of the alarming device, which would have triggered an alert and prevented the resident from exiting, directly contributed to the unauthorized leave of absence.
Removal Plan
- Re-assessed the elopement risk for R101 and implemented measures to prevent recurrence.
- Performed a resident count to ensure no other residents had eloped.
- Assessed all facility residents for risk of elopement for any previously unidentified residents at risk and ensured appropriate safety measures were in place.
- Reviewed and updated the facility Missing Guest/Elopement book.
- Re-education of the Elopement policy was initiated for all staff.
- Re-education of the Missing Guest Procedure for all staff was initiated.
- The Nursing Home Administrator was re-educated on the facility elopement policy and the expected information to be ascertained to ensure compliance with the facility policy across disciplines.