Failure to Prevent Elopement Due to Inadequate Assessment and Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and accident prevention for a resident with cognitive impairment and a history of agitation and confusion. Upon admission, the resident had diagnoses including encephalopathy, vascular dementia, and mood disturbances, and had demonstrated agitation and a desire to leave home prior to admission. Despite this, the facility's elopement risk assessment was completed incorrectly, omitting points for mobility status and being new to the facility, resulting in the resident not being identified as at risk for elopement. Consequently, the resident was not provided with a Wanderguard or specific interventions to prevent elopement, and the care plan did not address elopement risk or the resident's ongoing expressions of wanting to leave. The facility's monitoring procedures were insufficient, particularly at the main entrance. The front doors were unlocked during early morning hours before the reception area was staffed, and there was no alarm or staff presence to monitor residents exiting the building during this time. The resident was last seen in the early morning, and staff did not notice the absence until an hour later, at which point a search was initiated. The lack of supervision and monitoring allowed the resident to leave the facility unnoticed. The resident was found eight hours later, twenty miles away from the facility, after a Silver Alert was issued and family members assisted in the search. The resident sustained superficial abrasions and required evaluation in the emergency department. Interviews with staff confirmed gaps in the elopement risk assessment process, care planning, and entrance monitoring, all of which contributed to the resident's ability to elope from the facility without detection.
Removal Plan
- All facility residents were re-assessed to identify risk for elopement and ensure proper interventions were implemented.
- Identified residents at risk for elopement and ensure person centered care plans are in place with preventative measures to include the specified level of supervision for residents at risk for elopement.
- Reviewed elopement/missing resident policy to address the timing of searching for/reporting a missing resident to help ensure an expedited search.
- Education was provided to all staff on following the facility's updated elopement policy, accuracy of elopement assessments, monitoring resident's at risk for elopement and timely response to door alarms.
- Elopement risk assessments completed will be reviewed during clinical meeting to verify accuracy and ensure appropriate interventions were put in place.
- New elopement risk assessments were completed for all facility residents.
- Facility implemented cameras at facility entrance.
- Reviewed updated facility policy and procedure on elopement and coordination with medical director. Including updated elopement assessments, and addition of cameras at the facility entrance to ensure adequate resident supervision is in place to identify residents exiting the facility and to ensure facility policy and procedure meets current standard of practice.
- Facility Maintenance will complete audits to ensure door alarms are properly functioning. Audits will be completed on all shifts.
- IDT will review in clinical meeting any new admissions elopement assessments, incidents regarding changes in residents' behaviors, and document on eagle board to ensure proper assessments have been obtained and appropriate interventions have been implemented. Audits will be conducted. Results will be reviewed by QAPI Committee to determine compliance or additional follow up required.
- An Ad Hoc QAPI completed.