Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident, identified as high risk for elopement, was able to leave the facility on two separate occasions without staff knowledge. The first incident occurred when the resident, who had a history of wandering, confusion, and impaired decision-making, was found by police 0.5 miles from the facility after staff were unaware of his absence until contacted by law enforcement. The resident's medical record indicated a high elopement risk score, documented episodes of wandering, and family concerns about his tendency to leave, yet no interventions or care plan addressing elopement risk were in place at the time. Following the first elopement, the resident was returned to the facility and placed on one-to-one supervision, but there was no physician order for this intervention, and the resident was returned to a non-secured unit. Documentation revealed that cognitive assessments were not completed upon his return, and the care plan still lacked interventions for elopement risk. The facility also failed to submit a Self-Reported Incident (SRI) related to this event, and the incident was not documented in the facility's incident/accident log. A second elopement occurred when the resident, who was supposed to be on 15-minute checks, left the facility again and was missing for over 17 hours before being found by police 2.6 miles away. There was no documented evidence that the required 15-minute checks were performed, and staff interviews confirmed that checks were not consistently documented or performed as ordered. The facility did not report this elopement to the state health department, and the incident was again omitted from the SRI and incident/accident log. The lack of timely and appropriate interventions, failure to follow physician orders, and inadequate documentation contributed to the deficiency.
Removal Plan
- The facility initiated a search for Resident #10.
- The facility initiated a head count, and all residents were accounted for except for Resident #10.
- The facility administrator notified the police of Resident #10's absence.
- The police requested assistance from another police department who had access to a device with thermal capabilities.
- The Bureau of Criminal Investigations was contacted and a silver alert was completed and sent out statewide.
- The Sheriff's Office was notified and assisted with the search for Resident #10.
- The facility conducted an AD HOC Quality Assurance and Performance Improvement (QAPI) meeting.
- Resident #10 was found and transported to a hospital for an evaluation.
- The facility reviewed and updated the elopement policy to reflect clearer definitions on elopement, more concise instructions to staff on reporting elopement, investigation procedures, and notification to appropriate agencies and medical staff.
- Resident #10's care plan was updated to reflect resident now resides on the secured unit.
- The facility staff completed a whole house head count as part of the facility's daily audits of residents. All residents were accounted for.
- Resident #10 was placed on the facility secured unit.
- Resident #10 was assessed by the facility nurse with no significant injuries. The assessment revealed two open areas on the right foot assessed as abrasions.
- A whole house audit of all residents was completed to ensure all residents were accurately assessed for elopement risk and no new residents were identified as being high risk for elopement. All residents who were previously identified as being high risks had their care plans reviewed for accuracy and no inaccuracies were found.
- Facility Unit Manager initiated education on the facility elopement policy which included one Registered Nurse, four Licensed Practical Nurses, and two Certified Nursing Assistants.
- The facility continued education for all staff on the facility elopement policy. Five Licensed Practical Nurses, two Certified Nursing Assistants were educated in person. Director of Nursing and the Administrator were educated on the facility Elopement Policy. Medical Director and Certified Nurse Practitioner were educated on the Elopement Policy via the telephone.
- Sixteen Licensed Practical Nurses, thirty Certified Nursing Assistants, three Activity Employees, eight Housekeepers, ten Dietary Staff, four Office Staff, twenty-one Therapists, five Speech Therapists, and one Maintenance Director were educated on the facility Elopement Policy via the telephone.
- Two Registered Nurses, eleven Licensed Practical Nurses, twenty-seven Certified Nursing Assistants, three Dietary Staff, four Housekeeping Staff, two Office Staff, seven Therapists, and one Maintenance Staff were educated in person on the facility Elopement Policy.
- All residents who were assessed as a high risk for elopement had their care plans reviewed for accuracy and updated as necessary. No inaccuracies were found.
- The facility checked the elopement binders and verified they reflected the status of the residents in the facility. No changes were identified.
- The facility reviewed the Brief Interview for Mental Status (BIMS) for residents who were deemed at high risk for elopement to ensure the assessments were accurate. There were no changes made to the resident's assessments.
- The facility completed a second check of all Elopement Risk Assessments and Elopement Care Plans for Accuracy.
- One Licensed Practical Nurse, one Certified Nursing Assistant and one Office Staff member were educated on the facility Elopement Policy.
- No staff will be permitted to work at the facility who have not received and reviewed the updated facility Elopement Policy. Facility education on the Elopement Policy will be ongoing.
- All new hired employees will be educated on the facility Elopement Policy as part of the general orientation.
- Elopement drills and head counts were completed at various times/shifts. Staff knowledge and review of the drill was completed. The Administrator reviewed and verified no actual elopements occurred.
- The facility's Interdisciplinary Team members reviewed elopement care plans to ensure interventions were in place. No identified concerns were noted.
- The facility will complete weekly elopement drills with the drills rotating between day and night shift to ensure each shift will have at least four elopement drills. Drills will be done monthly and randomly thereafter.
- The facility will conduct head counts daily as part of their midnight census procedure which ensures that all residents are accounted for daily.
- All new residents will be assessed by the facility nursing staff and follow up completed to ensure proper assessments and interventions are in place for residents deemed to be high risk for elopement.
- Telephone interviews with staff verified they all had received education on the policies/procedures for elopement. All staff had knowledge of how to respond to an elopement situation. Staff reported there had been no elopements. The LNHA verified he had continued on-going training/education/drills for all staff on elopement policies/procedures.
- Review of the audits revealed elopement drills were completed successfully and on-going monitoring continued.
- The facility denied any further elopements.