Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Lapses in Environmental Controls
Penalty
Summary
A cognitively impaired resident with a history of exit-seeking behaviors and prior elopement attempts was not adequately supervised, resulting in the resident eloping from the facility. The resident was on a 15-minute monitoring schedule, and staff last observed the resident pacing in the hallway before the incident. The assigned CNA was providing care to another resident and did not inform the nurse that she would be unavailable to monitor the resident at risk for elopement. The nurse was also engaged in medication pass and was not aware that the CNA was occupied, leading to a lapse in supervision. During this period, the resident was able to leave the unit, likely by following a visitor into an elevator that did not require a keypad code for operation at the time. The facility's protocol did not require a code to use the elevator, allowing residents or others to access the first floor without restriction. The receptionist, responsible for monitoring the main entrance, did not notice the resident leaving, possibly due to increased activity and the presence of a transport company at the entrance. The resident exited the building without being detected and was later found in a nearby strip mall parking lot. Facility documentation and staff interviews confirmed that the resident was identified as an elopement risk, with care plans and progress notes indicating the need for close observation and safety precautions. Despite these documented risks and interventions, the lack of communication between staff and insufficient environmental controls contributed to the resident's unsupervised exit from the facility.
Removal Plan
- Resident #2 had head-to-toe assessment, placed on one-to-one monitoring for observation and emotional support.
- If elevator #1 is required, the visitor, vendor and/or transportation staff will be escorted by a staff member on and off elevator #1 until elevator access could be restricted.
- Restricted access to elevator #1 by installing keypad inside elevator and designating only receptionists, designees who cover receptionists, and leadership staff have the code, resulting in the elevator being inoperable to all other staff, visitors and residents.
- All codes changed and will be changed monthly, or as needed.
- All exit doors checked by maintenance for proper functioning and locking mechanism.
- Facility reviewed and updated elopement binders on each unit and by the receptionist area.
- Facility audited EMRs for presence of resident's profile pictures.
- Facility audited new admissions for presence of the elopement risk evaluation and corresponding care plan (if applicable).
- Facility conducted additional elopement drills on day, evening, and night shifts.
- Additional security measures added to include keypads inside and outside of the elevator, restricting access to elevator operation.
- Court-1 (first floor) outside Elevator #1 keypad code needed to access elevator by designated staff only.
- Elevator #1 keypad inside elevator code needed to operate first floor button (#1) to activate elevator to access first floor when on Court-2 (second floor).
- Code only given to receptionist, and designees who cover receptionists, and leadership staff.
- Receptionist and designees who cover the desk educated not to give out keypad codes.
- Added alarms to all court building stairwell exit/egress.
- Larger sign at the entrance to the elevator, redirecting visitors to the other elevator.
- Receptionist and designees who cover receptionists educated to wait to release the main entrance doors until anyone attempting to exit is identified as staff, visitors, vendors and authorized resident only.
- Elopement policy reviewed.
- ADON or designee, initiated re-education of staff members on the elopement policy and procedure.
- ADON or designee, initiated education to changes to the elevator #1 access with keypads restricting operation.
- Agency, PRN, and employees on PTO will be educated prior to their next scheduled working shift/day.
- The DON or designee audited current residents for elopement risk and implemented immediate interventions if a high elopement risk score is triggered.
- The DON or designee audited new admissions for elopement risk and implement immediate interventions if a high elopement risk score is triggered weekly.
- The DON or designee evaluated elopement risk for residents who present with new wandering/exit seeking behaviors as soon as the behavior is identified and weekly.
- The DON or designee conducted weekly observations of staff/visitors/vendors safety practices when entering and exiting secured units.
- Findings from audits and observations will be reported to the monthly QAPI Committee.