Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A severely cognitively impaired resident with a history of wandering behaviors eloped from the facility without staff knowledge. The resident, diagnosed with unspecified dementia, mood disturbance, anxiety, and Alzheimer's disease, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. The resident was last observed by a registered nurse at approximately 4:45 p.m., and was discovered missing by their assigned certified nurse aide at around 5:05 p.m. Despite a search initiated by staff and the activation of a Code Gray (elopement/missing person code), the resident was not found within the facility. The local police later contacted the facility, having found the resident in a nearby town approximately three miles away, and returned the resident to the facility. The facility's policy required systematic monitoring and management of residents at risk for elopement or unsafe wandering, including identification, assessment, and implementation of interventions to reduce risks. However, interviews with staff and review of facility documents revealed that only wandering risk assessments were conducted, not elopement risk assessments. The care plan for the resident included interventions for wandering and elopement risk, but staff did not place the resident on 15-minute checks, as they were not considered exit-seeking. The Director of Nursing and the Licensed Nursing Home Administrator both stated that the facility did not perform elopement risk assessments, only wandering risk assessments, and that the care plan may have mischaracterized the resident's risk. Staff statements indicated that the resident was known to wander and pace the unit, but there was no clear protocol for increased supervision or monitoring for exit-seeking behavior. The facility was unable to determine how the resident exited the building, as all doors were reported to be locked. The receptionist did not observe the resident leaving through the front entrance, and dietary and housekeeping staff did not recall seeing the resident exit. The lack of adequate supervision and failure to properly assess and monitor for elopement risk led to the resident's unsupervised departure from the facility.
Removal Plan
- All residents were visually checked to be sure they were safe and all staff facility wide were informed to check all residents to ensure safety.
- A complete head count of residents was conducted, and all other residents were accounted for.
- Audit to review the residents at risk of elopement assessments was conducted.
- Full house audit for residents at risk for elopement with review and revision of the care plans was conducted. This included implementation of interventions consistent with the residents' needs, goals and care plans to reflect current risk of elopement.
- The residents were monitored when noted in the common areas such as dayroom, dining rooms, and attending activities.
- The facility has now increased the monitoring to Q 15-minute monitoring Q shift.
- Staff were re-educated on the Elopement Policy and Procedure.
- At risk residents for elopement are identified with a discreet visual indicator listed under special instructions in the residents EMR (Electronic Medical Records).
- Elopement binders located on each unit and front entrance were reviewed and revised with the resident's profile picture in color.
- All exits, windows, and keypads were checked and functioning.
- Keypad codes were changed.
- Facility added monitoring rounds every 15 minutes for identified high-risk residents to maintain safety.
- Audit monitoring tool sheets will be completed by direct care staff and completion reviewed by the DON/Designee.
- Facility implemented a new protocol for Family/Vendors/Visitors to sign in upon entering and sign out prior to exiting the facility.
- Director of Maintenance conducted a full house audit of the keypad doors and windows noted secured, and functioning.
- The facility Director of Maintenance, Director of Housekeeping, and the Administrator will maintain the keypad codes.
- Director of Maintenance will revise the schedule for changing keypad codes, making changes more frequent to monthly to the exit doors located at the end of the units.
- Visitor Communication Signage is located at the vestibule alerting visitors and staff to monitor the surroundings prior to entering the lobby to ensure the safety of the residents.
- Facility Educator provided mandatory re-education for staff (nursing, direct care, dietary, housekeeping, maintenance, and department heads) on elopement prevention, supervision, and emergency response.
- Ongoing training will be provided with any staff on all shifts or vacations prior to the start of the next schedule shift.
- Facility Educator will continue to incorporate the Elopement prevention training into new hire orientation and annual education.
- Facility Educator provided mandatory training on the new implementation of identifying residents at risk for elopement under special instructions in the residents EMR (Electronic Medical Records).
- Facility Administrator conducted QAPI Ad Hoc (Quality Assurance and Performance Improvement) meeting with the Interdisciplinary Team to review the residents at risk for elopement care plans, interventions and elopement assessments.
- Quarterly elopement drills will be conducted to reinforce emergency response.
- Monthly review of elopement risk assessments by the interdisciplinary team will be conducted and revised as needed.
- A QAPI (Quality Assurance and Performance Improvement) has been initiated to report on the above monitoring and auditing procedures.
- Results of the audits and findings, if any, will be presented to the monthly QAPI (Quality Assurance and Performance Improvement) meeting for review and revised as deemed appropriate.
- Monitoring/Auditing and reporting will continue for a minimum of three months.