Elopement Due to Inadequate Supervision and Resident Identification
Penalty
Summary
A deficiency occurred when a resident, identified as an elopement risk with a BIMS score of 6 indicating severe cognitive impairment, was able to exit the facility without authorization. The resident, who had diagnoses including Wernicke's encephalopathy and vascular dementia, was last seen in the main lobby by her assigned CNA before the CNA left for a scheduled lunch break. Upon the CNA's return, the resident was missing from both the common area and her room, prompting immediate notification to the RN/MDS nurse and the initiation of a facility-wide search. The investigation revealed that the resident followed a dietary aide out of the front door as the aide was leaving at the end of his shift. The dietary aide, who did not recognize the individual as a resident due to her street clothes and purse, assumed she was a visitor and allowed her to exit behind him. The aide later observed the resident attempting to enter a parked vehicle in the lot before returning to the facility entrance. The resident remained outside for approximately 35 minutes before being found knocking on the front door by another CNA during the search. At the time she was found, the resident was appropriately dressed, carrying her purse, and did not display signs of distress or injury. Staff interviews confirmed that the resident was care-planned as an elopement risk, wore a yellow identification bracelet, and was listed in the facility's wander book. Despite these precautions, the dietary aide was unaware of her status and allowed her to exit. The facility is located near a four-lane highway and industrial complex, with no fencing or restricted barriers between the grounds and the surrounding area. The failure to provide adequate supervision and to ensure staff could properly identify residents resulted in the resident's unauthorized exit and exposure to potential harm.
Removal Plan
- CNA#1 reported Resident #1 missing to MDS Nurse #1, who called Code W (elopement), and all staff began a search of the facility and perimeter.
- Resident #1 was brought inside with no signs of distress after being found outside.
- Administrator was notified by MDS Nurse about the incident.
- MDS Nurse completed a body audit with no signs or symptoms of injury.
- MDS Nurse completed a head count of all current residents in the facility.
- MDS Nurse notified Resident #1's representative of the incident.
- Medical Director was notified of Resident #1's incident and no new orders were given.
- Administrator arrived at the facility and checked that all doors were functioning properly.
- Administrator interviewed all employees and any residents that had interactions with Resident #1 prior to the incident.
- Administrator began in-service for all employees on elopement policy and procedures; all staff would be in-serviced before returning to their next shift.
- Administrator reported incident to State Agency.
- An emergency Quality Assurance & Performance Improvement (QAPI) committee meeting was held to discuss incident, actions taken, and further interventions.
- Social Services Director spoke with Resident #1 and noted no psychosocial harm due to incident.
- Maintenance Director conducted a quality check of all doors to make sure they were operating as expected and door alarms were added to all of the doors.
- Regional Director of Operations interviewed Resident #1 and Resident #2 for any details they remember about the incident.
- Education of elopement policy and procedures with dietary staff, including Dietary Aide #1.
- Wander assessments were completed on all active residents in the facility by DON, RN #1, LPN #1, and Medical Records LPN.
- Maintenance Director began elopement drills for all shifts.
- A follow up QAPI committee meeting was held by Administrator to discuss that all interventions were in place.
- Maintenance will conduct a quality check of all doors, an elopement drill on each shift and put alarms on each of the doors.
- Administrative nurses completed wander assessments on all current residents, update care plans and wander books accordingly; completed a 100 percent audit of care plans; completed 100 percent audit of wander books located at both nurse's stations.
- Social services would interview Resident #1 for any psychosocial harm.
- Administrative staff would in-service all employees on elopement policy and procedures before their next shift.
- Elopement drills on all shifts and one elopement drill per week for four weeks on alternating shifts and one per month for six months on alternating shifts.
- Person-centered in-services will be completed with all staff for any new residents identified as an elopement risk or any current residents who are newly identified as an elopement risk.
- Incident was reported to Attorney General's office by Administrator.