Failure to Secure Exit Doors and Implement Individualized Elopement Interventions
Penalty
Summary
A deficiency occurred when the facility failed to ensure that exit doors were secured and did not implement individualized interventions to prevent or reduce the risk of elopement for a resident with a known history of exit-seeking behaviors. The resident, who had diagnoses of dementia, depression, and anxiety, was assessed as being at risk for elopement due to cognitive impairment and independence in wheelchair locomotion. Despite documented exit-seeking behaviors, the resident's care plan only included a Wander Guard device as an intervention, and there was no evidence that the care plan was reviewed or revised after the resident demonstrated further exit-seeking behavior. On the evening of the incident, the resident expressed intentions to leave the facility to both a nursing assistant and a registered nurse. The staff did not increase supervision, communicate the resident's exit-seeking behavior to other staff, or revise the care plan to address the immediate risk. The resident was able to exit the facility through two unsecured doors, one of which had a known malfunctioning Wander Guard alarm that did not activate. The resident left the building unwitnessed and was later found and returned by a passerby. Interviews and document reviews revealed that staff were aware of the resident's risk but did not implement additional or individualized interventions after prior incidents of exit-seeking. There was also a lack of a system to ensure that all exit doors were secured, and staff were not educated on developing or revising care plans to address exit-seeking behaviors. The facility's policy required updating assessments and care plans after an elopement, but this was not followed prior to the incident.
Removal Plan
- Provide education with knowledge checks to all nursing staff on revising care plans for individualized, immediate interventions for exit seeking behaviors.
- Provide education with knowledge checks to all staff on identifying exit seeking behaviors, implementing appropriate interventions for redirection and increased supervision.
- Provide education on when to notify and communicate with other staff about elopement risk concerns.
- Provide education on when to ask passerby citizens about an elopement, such as where the resident was found, what the resident was doing and what their mental status was.
- Identify staff who have a key to the locked door.
- Develop a door lock check system that assures the two doors involved with the elopement are locked.
- Check the doors by nursing staff and document in a sign off sheet.
- Review the elopement policy and procedure.
- Educate staff on the elopement policy and procedure.