Failure to Prevent Elopement Due to Inadequate Supervision and Environmental Safety
Penalty
Summary
A facility failed to ensure a safe environment and provide adequate supervision to prevent the elopement of a severely cognitively impaired resident with known exit-seeking behaviors. The resident, who was dependent on staff for toileting hygiene, lower body dressing, and required supervision for eating, left the facility through a window in his room. The facility was unaware of the resident's absence for an undetermined length of time, with the last known sighting at approximately 10:30 PM and the resident being found 18 hours later, 5.1 miles away beside a busy street. The window in the resident's room was found open with the screen pushed out, and the window stop, which should have prevented the window from opening fully, was missing. Staff had not been checking windows as part of their routine safety checks prior to the incident. The resident had a documented history of wandering and exit-seeking, including removing his Wander Guard device and making statements about wanting to leave. Despite these behaviors, the care plan was not revised after actual exit-seeking incidents, and interventions were not updated to address the resident's ability to remove safety devices or to increase monitoring. Video footage confirmed that no staff entered the resident's room for several hours overnight, and the resident's bed was undisturbed, indicating a lack of monitoring. Staff interviews revealed inconsistent rounding practices, with some staff only entering rooms if residents were incontinent, and there was no documentation of increased monitoring for high-risk residents. Additionally, the facility had a pattern of complaints regarding staff not providing care or answering call lights during the overnight shift, with 22 complaints logged over 15 months. Disciplinary records for staff included failures to provide care and respond to resident needs during the night shift. Management was aware of these issues but did not conduct audits or provide oversight during the critical overnight hours. The lack of supervision, failure to implement and update care plan interventions, and inadequate environmental safety checks directly contributed to the resident's elopement and the resulting Immediate Jeopardy finding.
Removal Plan
- Staff who were not available during the training will be trained before being allowed to work, and must attain a 100% score on post-training tests; retraining provided if less than 100%.
- Staff were provided education/re-education on frequency of monitoring residents, especially those with wandering and exit seeking behaviors, including notification procedures and enhanced supervision protocols.
- Residents identified as high risk for elopement are added to the Elopement Binder and discussed in staff huddle meetings.
- High risk for elopement residents are monitored by nurses and nursing assistants; DON and clinical managers conduct daily unit rounds, and Nurse Supervisor/MOD on weekends.
- Residents at high risk for elopement are reviewed during daily clinical meetings and weekend clinical meetings by MOD/Nurse Supervisor.
- Elopement risk reassessments were completed for all residents by DON, unit manager, MDS nurse, and VP of Clinical Services.
- Care plans for residents identified as high risk for elopement were reviewed and updated by DON, unit manager, MDS nurse, and VP of Clinical Services.
- Ad-Hoc QAPI meeting was completed with leadership and clinical team to discuss the incident and facility actions.
- Elopement drills were conducted and will continue daily for 7 days, weekly for 3 months, then monthly.
- Signs were posted on lobby doors asking visitors not to assist residents outside the door.
- All doors and windows in the facility were checked for security and function; exit stopper door alarms checked for proper function.
- If door/window checks reveal a problem, Maintenance Director/Staff will notify Administrator/DON and assign staff to monitor until fixed.
- Daily checks of doors and windows for 3 months, including weekends, by Maintenance Director/Staff/Administrator/MOD/Charge Nurse; QAPI team to review after 3 months for frequency adjustment.
- Policies related to exit-seeking behaviors, elopement and wandering care plan, missing resident, responding to alarms, and resident safety and supervision were reviewed.
- Staff were provided training on exit-seeking behaviors, elopement and wandering care plan, missing resident, redirecting residents, responding to alarms, and resident safety and supervision; posttests required 100% score.
- Agency staff, if used, will receive the same training and posttest requirements as facility staff.
- DON, SDC, and Unit Manager will monitor nursing documentation and conduct unit observation rounds to identify new or worsening exit seeking/wandering behaviors and ensure care plans are followed.
- During weekends, Nurse Supervisor and/or MOD will review documentation and conduct unit observations for exit seeking/wandering behaviors and care plan compliance.
- Any concerns identified during monitoring will be addressed immediately, with notification to DON or Administrator and implementation of additional interventions as needed.
- New admissions and re-admissions will be reviewed for elopement risk by SSD, DON, Unit Manager, SDC, or MDS Nurse; appropriate care plan interventions and elopement book updates will be ensured.