Failure to Provide Adequate Supervision and Elopement Prevention
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent the elopement of a resident who was identified as being at high risk for elopement. The resident, who had diagnoses including dementia, insomnia, wandering, restlessness, and agitation, was assessed as having memory impairment and was able to ambulate independently. The care plan and physician orders required 1:1 supervision and the use of a roam alert bracelet due to the resident's history and ongoing behaviors such as exit-seeking, attempting to use elevators, and previously eloping from another facility. Despite these interventions, there were multiple documented incidents where the resident was found attempting to access elevators, standing by exit points, and even obtaining and hiding door codes, yet the facility did not consistently implement or evaluate the recommended 1:1 supervision in a timely manner. On the day of the incident, the assigned 1:1 staff member left their post and was not replaced, leaving the resident unsupervised in violation of the care plan and physician's order. During this period without supervision, the resident was able to use a previously obtained door code to exit the facility through a stairwell door, as later confirmed by camera footage. The facility also failed to change the door codes after discovering the resident had obtained them, and did not provide required elopement prevention training to the staff assigned to the resident at the time of the incident. Additionally, the facility did not immediately initiate a search when the resident's alert bracelet alarmed, and there was no evidence that staff on the unit had received the necessary training as outlined in the facility's Immediate Jeopardy action plan. Further review revealed that 29 residents on the same unit were assessed as being at risk for elopement, yet there was no documentation that staff had received the required education on elopement prevention prior to their shifts. The facility's failure to provide adequate supervision, implement timely interventions, and ensure staff were properly trained directly resulted in the resident's unwitnessed elopement from the building, which was only discovered after the resident could not be located and was later found offsite by police.
Removal Plan
- Resident 2's room was changed to a secure unit.
- The facility changed all the door and elevator codes.
- The facility updated the 1:1 policy to include that staff is never to walk away from the assigned resident until another staff member takes their place.
- The facility educated all staff regarding the new 1:1 policy and not sharing door codes.
- The facility educated staff that a search should occur immediately if a door alarm is sounding.
- The facility instructed staff not to utilize fire alarm doors for everyday use to decrease alarm fatigue.
- The facility will continue to assess residents' risk of elopement upon admission, quarterly, and with events.
- The Nursing Home Administrator will update the pre-admission review of elopement risk to ensure the facility can safely manage a resident at risk of elopement.
- Monthly department head meetings will be held for the leadership team to discuss elopement events.
- Staff members observed to be giving out door and elevator codes to visitors or residents will receive disciplinary action.