Failure to Identify and Address Elopement Risk Resulting in Resident Exiting Facility Unnoticed
Penalty
Summary
The facility failed to identify and address the elopement risk of a resident with severe cognitive impairment and a history of behaviors requiring constant redirection. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease and Schizophrenia, was initially assessed as low risk for elopement upon admission. Despite exhibiting behaviors such as wandering, loud vocalizations, and hallucinations, no updated elopement risk assessment or care plan interventions were completed after the resident exited the facility on one occasion. On two separate occasions, the resident was able to leave the facility without staff awareness. The first incident occurred when the resident followed staff out the front door after it was unlocked by a receptionist. The second incident involved a newly hired receptionist who mistakenly identified the resident as a visitor and allowed them to exit. In both cases, staff were unaware of the resident's absence until after the fact, and the resident was found outside the facility, once by a staff member driving to work and once by facility supervisors. Interviews with staff revealed a lack of communication and awareness regarding the resident's previous elopement and ongoing behaviors. Key personnel, including the assigned nurse and other staff, were not informed of the prior incident or the need for reassessment. The DON confirmed that no reassessment or new interventions were implemented after the initial elopement, and the administrator stated that only the receptionists were in-serviced following the incidents. The facility's policy required reassessment and intervention upon changes in resident behavior or condition, which was not followed in this case.
Removal Plan
- Resident wander assessment completed for the at-risk resident.
- Resident care plan reviewed by the interdisciplinary team and updated.
- Resident monitored by psychiatry for behaviors and medication management.
- All residents in the facility reassessed for risk of elopement to identify those at risk.
- Audit completed by the facility's clinical management team on all residents who trigger for elopement risk.
- Care-plan review for residents deemed at risk for elopement to ensure appropriate interventions are in place.
- Residents deemed at risk for elopement are included in all facility elopement binders, which are located on the nurse's unit and at the reception area.
- In-servicing for staff initiated by DON/Designee on the elopement guideline.
- Signage made visible throughout the building for staff and visitors to be aware of residents who may be around when walking through doors.
- In-servicing for licensed nurses initiated by the DON/Designee on ensuring a resident is reassessed for wandering when showing behaviors to ensure accuracy of care plan and interventions.
- The DON/Designee will review residents who are at risk for elopement to ensure wander/elopement assessments are current and interventions are accurate.
- Results reported to the QA committee for monitoring and follow-up.