Failure to Prevent Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident identified as high risk for wandering. The resident, who had a diagnosis of dementia, hypertension, and insomnia, and was assessed as having moderately impaired cognition, exhibited a history of wandering and aggressive behaviors. Despite these risk factors, the resident was transferred from a secured dementia unit to a non-secured long-term care unit without documented interdisciplinary team review or updated elopement evaluation prior to the move. The care plan indicated the resident was at risk for elopement, but interventions and assessments were not consistently updated or implemented as required by facility policy. On the day of the incident, the resident was able to exit the facility through an emergency door that was not properly secured. Staff interviews and resident accounts confirmed that the door was either left unlatched or the resident was able to open it, possibly by guessing the keypad code or due to the door not being pulled shut. The resident was found outside in the parking lot, having exited the building without staff knowledge. Staff were unaware of the resident's absence until alerted by another resident, and there was no immediate staff presence in the area to prevent the elopement. Following the incident, it was revealed that there was no incident report completed, no documentation of family or physician notification, and no reportable notification to the Department of Health. The facility's policies on elopement, accidents, and care planning were not followed, as evidenced by the lack of timely assessment, care plan updates, and supervision. The Director of Nursing confirmed that the facility failed to provide adequate supervision, resulting in the resident's elopement and the creation of an immediate jeopardy situation.
Removal Plan
- Staff retrieved Resident R1 from the rear parking lot after being alerted by Resident R2.
- Nursing staff will be re-educated on updating the elopement care plan form immediate interventions and elopement assessment.
- All residents will be reassessed by the unit manager/designee for an elopement risk.
- All staff will be educated on elopement risk and assessments, care plans and supervision of residents by the unit manager/designee.
- A care plan with measurable goals and interventions for residents will be implemented to identify residents at risk for eloping by the unit manager/designee.
- Review and revise policies if needed to identify residents who are at risk for eloping.
- Door will be monitored by staff stationed at the door until vendor arrives to verify functioning of the door and residents are unable to exit.
- Facility will review the incidents at an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting.
- New admissions, change in condition or any new behavior will be monitored by the DON/designee to ensure elopement assessments are completed and care plans updated as required.
- Maintenance/designee will audit the doors are secure.
- Findings of audits will be submitted through facility QAPI program.
- Vendor will check that everything is functioning on the door, the magnetic lock and the keypad to the door itself.
- The door alarm will be set to alarm instantly instead of a delay.
- Deliveries will be changed to the front door.
- Code will be changed to an eight-digit number instead of four digits.
- All staff will be educated on risk, assessments, care plan, and supervision and verified with signatures.
- In-person interviews will be conducted of all staff to confirm education and understanding.
- Residents identified as elopement risks will be identified, including new residents at risk for elopement within the dementia secured unit.
- Policy will be reviewed and revised by the Director of Nursing to identify residents who are at risk for eloping.
- Door monitor by staff will be in place.
- Ad Hoc QAPI will be held.
- Audit tool for new admissions, change in condition or any new behavior will be used to ensure elopement assessments are completed and care plans updated as required and reviewed at the QAPI meeting.
- Audit by maintenance will be completed on the doors being secure and reviewed at the QAPI meetings.