Failure to Prevent Elopement Due to Inadequate Supervision and Policy Noncompliance
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent an elopement for a resident identified as being at risk. The resident, who had diagnoses including vascular dementia, syncope, and cerebral infarction, was independently ambulatory and had documented memory impairment. Despite being assessed as a wanderer at risk for elopement, the resident was able to repeatedly remove his alert bracelet, which was intended to prevent unauthorized exits. Facility policy required that residents capable of removing their alert bracelets be issued a stronger, tamper-resistant band and, if still able to remove it, be placed on one-to-one observation. However, after the resident removed his alert bracelet on multiple occasions, there was no documented evidence that a stronger band was provided or that one-to-one observation was implemented as required by policy. Additionally, there was no documentation that the resident's care plan was updated to include interventions addressing his elopement risk, wandering behavior, or alert bracelet use. On one occasion, the resident was found off the unit and returned, but later the same day, he was able to leave the facility undetected and was found by police walking along a road a mile away. Staff interviews confirmed the lack of appropriate interventions and care plan updates, and the failure to follow facility policy led to an Immediate Jeopardy situation.
Removal Plan
- Resident 1's room was changed to a secure unit, and a new alert bracelet was placed on the resident. The resident's care plan was updated to include risk for elopement. Resident 1 was placed on 1:1 observation.
- The facility conducted an immediate audit of all residents with alert bracelets to ensure they were intact and with the appropriate band.
- The facility conducted an audit to ensure all residents with an alert bracelet had an appropriate care plan in place.
- The facility created a log to monitor each alert bracelet and band to ensure the correct band is in place, and that the policy regarding stronger bands is being followed.
- The receptionists will review the binder of at risk residents at the start of their shifts for changes and initial a log.
- The facility will update the template for 1:1 orders in the electronic health record.
- The facility educated all staff in the facility on the facility's procedure for alert bracelets, stronger bands, and resident care plans. All staff that were available were immediately educated. Other staff will be re-educated prior to the start of their next shift.
- Weekly audits of alert bracelets, bands, logs, and care plans will be completed and the results discussed at QAPI (Quality assurance, performance improvement) committee.
- Signs are posted with instructions to not share door codes and to be aware of residents who may try to exit.