Failure to Prevent Elopement and Inadequate Supervision of Exit-Seeking Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions for residents identified as having exit-seeking behaviors, resulting in multiple deficiencies. One resident with a history of dementia, cognitive impairment, and exit-seeking behavior was admitted and initially assessed as low risk for elopement, despite documentation of wandering and a prior history of exit-seeking at the hospital. The resident was provided with a wander guard, but staff did not accurately update the elopement risk assessment when the resident continued to display exit-seeking behaviors. On the day of the incident, the resident expressed a desire to leave, was redirected multiple times, and ultimately eloped from the facility without staff knowledge. The facility failed to promptly and correctly implement its missing resident protocol (Code Orange), with staff not announcing the code as required, not stationing staff at all exits, and not completing required documentation. The resident was later found offsite by local authorities after a family member was contacted by the resident. Another resident with dementia and moderate cognitive impairment also exhibited exit-seeking behaviors, including multiple attempts to exit the facility and setting off alarms. Despite these behaviors, the facility did not complete updated elopement risk assessments as required by policy. The resident was ordered to have a wander guard, but there was an incident where the resident removed the device, and it was not immediately replaced by staff. The resident's information was also missing from the facility's elopement binder, which staff relied upon to identify residents at risk for elopement. Staff interviews revealed a lack of awareness regarding the need for reassessment and inconsistent monitoring of the wander guard's placement and function. Throughout these incidents, facility staff demonstrated a lack of adherence to established policies for elopement risk assessment, care planning, and emergency response. Staff failed to communicate effectively, did not follow the required steps for Code Orange activation, and did not ensure that all staff were aware of their roles during a missing resident event. Documentation was incomplete or missing, and not all staff involved were interviewed during the facility's internal investigation. These failures affected at least two residents and resulted in noncompliance with federal requirements for accident prevention and resident safety.
Removal Plan
- Resident was placed on 1:1 supervision to ensure safety and to not leave the building unattended once returned to the building.
- Resident was evaluated by nursing staff with no new impairments and seen by the nurse practitioner (NP).
- Resident remained on 1:1 supervision and discharged from the facility.
- Resident was placed on 1:1 supervision as a precaution.
- The wander guard was placed back on Resident and secured the same day it was observed to be off.
- Admission Record for Resident was placed in the elopement binder at the front desk; all other binders on the units were already updated.
- The facility licensed nursing staff will conduct new elopement assessments on all residents to determine elopement risk with follow-up based on findings.
- Any newly identified residents will be assessed for a wander guard by Director of Nursing, and it will be placed appropriately.