Elopement and Smoking Safety Deficiencies
Penalty
Summary
A cognitively impaired resident with a history of elopement exited the facility without staff knowledge and was found by local police in the middle of a residential street approximately 1.7 miles from the facility. The resident was confused, speaking in his native language, and seeking a local ethnic meat market. The resident was subsequently transported to a local hospital for evaluation. Prior to this incident, the resident had previously eloped from the facility's smoking area by kicking open a gate and was returned by emergency services. Despite being identified as an elopement risk with documented wandering and exit-seeking behaviors, the resident's care plan and interventions were not consistently updated to reflect the need for increased supervision, such as 1:1 monitoring, and behavior monitoring was not completed on the shift when the elopement occurred. Staff interviews revealed that the resident was known to be restless, had poor safety awareness, and required significant redirection. On the evening of the incident, the staff member assigned to provide 1:1 supervision for the resident called off, and administration was not notified, resulting in the resident not receiving the required supervision. The facility was unable to determine exactly how the resident exited the building, but it was believed the resident left through the front door, which was keypad-secured. The facility's elopement prevention policy included regular rounds, environmental modifications, and protected lists of at-risk residents, but these measures were not sufficient to prevent the incident. Additionally, the facility failed to maintain a safe environment related to resident smoking. Observations showed that smoking materials, including cigarettes and lighters, were not kept in locked areas as required by facility policy. Multiple residents were found with smoking paraphernalia unsecured in their rooms, and some did not have required smoking contracts or access to secure storage. The outdoor smoking area was observed to have cigarette butts and combustible items mixed in ash trays, further contributing to accident hazards.
Removal Plan
- Local police notified facility that Resident #117 was found outside and transported to the hospital.
- A headcount was completed by facility staff to ensure each resident was accounted for.
- Resident #117 returned to the facility and was immediately assessed by the nurse.
- Resident #117 was placed on one on one (1:1) supervision with a plan for 1:1 supervision to remain in place until the resident was no longer identified as high risk for elopement which would be assessed quarterly using the wandering observation tool.
- Maintenance Director completed an audit to validate all windows and doors were secure and functioning properly.
- The DON/designee reported to the facility Quality Assessment and Performance Improvement (QAPI) committee the concerns related to Resident #117's elopement.
- The QAPI committee met to complete a root cause analysis.
- Maintenance Director changed all secure door codes.
- LPN completed a wandering assessment, pain assessment and head to toe assessment on Resident #117.
- The Administrator conducted staff education for all facility staff in person, via Onshift software (e-learning platform) and via phone calls related to Elopement prevention and management overview and Unit Supervision with emphasis on safety and supervision.
- Resident #117's physician and emergency contact was notified.
- The clinical interdisciplinary team which consists of the Director of Nursing, assistant Director of Nursing and Unit Managers completed wandering/elopement assessments on all residents.
- Elopement/wandering care plans were reviewed for all residents at risk by the DON/designee.
- The facility elopement binder was reviewed by the DON/designee.
- Resident #117's care plan was updated by Minimum Data Set Nurse to include 1:1 supervision for an elopement intervention.
- Two residents (Resident #37 and Resident #100) care plans were updated with elopement interventions by Minimum Data Set Nurse.
- The facility implemented a plan to monitor for ongoing compliance, elopement drills would be completed twice weekly for two weeks, then weekly for two weeks. The drills would be conducted by the DON/designee on night shift, day shift, evening shift and day shift.
- The Administrator/DON/Designee began calling the facility at the start of each shift to ensure coverage of one-on-one (1:1) care providers for Resident #117 and others as needed. This would continue every shift indefinitely until the facility Quality Assessment and Performance Improvement (QAPI) committee deemed appropriate changes.
- The facility implemented a plan for the DON/designee to complete observation audits to ensure resident(s) who had one on one supervision were provided five days a week every three months.
- The DON/designee would complete observation audits to ensure interventions were in place for elopement risk residents, five days a week for three months.