Failure to Prevent Elopement Due to Inadequate Supervision and Lapses in Elopement Protocol
Penalty
Summary
The facility failed to provide adequate supervision and accident hazard prevention for two residents identified as high risk for wandering, resulting in both residents eloping from the facility. For one resident with diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, the initial admission assessment identified a high risk for wandering, but there was no documented evidence that elopement or wandering interventions were developed or implemented after this determination. The resident was able to exit the building unsupervised, with staff only becoming aware after being notified by the resident's family. Staff interviews and witness statements confirmed that the resident was found outside the facility, and it was later discovered that a wander guard device had not been placed on the resident at admission, despite the high-risk assessment. Another resident, with diagnoses of high blood pressure, anxiety, and depression, also demonstrated exit-seeking behavior and was identified as an elopement risk. The care plan included interventions such as issuing a wandering device and frequent monitoring, but the resident was able to leave the building and was found outside in the parking lot by staff. Documentation revealed that the resident had previously cut off a wander guard device, and at the time of the elopement, the device was not found on the resident. Staff statements indicated confusion about the monitoring of the front entrance, and the door was found to be unlocked and unattended at the time of the incident. The facility's failure to implement and maintain effective elopement prevention measures, including the timely application of electronic monitoring devices and adequate supervision, directly resulted in both residents leaving the premises without staff knowledge. The lack of consistent communication, incomplete documentation, and lapses in monitoring procedures contributed to the residents' ability to elope, creating an immediate jeopardy situation as determined by the surveyors.
Removal Plan
- The facility Administrator, and or designee, will review current elopement policy for accuracy and update as needed.
- All residents will be evaluated for risk of elopement by the facility Director of Nursing, or designee.
- Any new identified residents as at risk of elopement will receive orders from physician for use of wanderguard bracelet and care plan will be updated accordingly by facility Director of Nursing, or designee.
- An audit of all residents identified as at risk for elopement will have their care plan reviewed to ensure resident centered interventions are in place, completed by facility Director of Nursing, or designee.
- All staff, both facility and agency, will be educated by the facility Director of Nursing, or designee, regarding elopement policy, identifying residents at risk, and implementing interventions.
- The facility Administrator and Director of Nursing will complete a root cause analysis as to what system failed allowing this elopement to occur.
- Facility Administrator and Director of Nursing will review the procedure on the front door monitoring, this to include functionality of wanderguard system, as well as the schedule of personnel monitoring front entrance.
- The front door wanderguard codes have been changed and code knowledge limited to administrative staff.
- Facility door will be secured and code use will be required for entry or exit. Compliance will be monitored through audits.
- Audits will consist of door security assessment by facility Administrator, or designee, audit of resident risk assessments will be completed by the facility Director of Nursing, or designee, and an audit of all resident care plans who were identified at risk of elopement will be completed by the Director of Nursing, or designee.
- Results will be reviewed at QAPI (Quality Assurance and Performance Improvement Committee) to be completed by NHA.