Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of depression, repeated falls, and chronic atrial fibrillation was able to exit the facility unsupervised. The resident was last seen by staff at 10:37 AM and subsequently left the building behind a hospice nurse, with no staff intervening to prevent the exit. The resident was observed by a physical therapist assistant (PTA) leaving the facility, but the PTA assumed the resident was accompanied by staff and did not verify this or intervene. The resident continued out of the facility and was not stopped or redirected by any staff members, despite facility policies requiring supervision and intervention for residents at risk of elopement. The resident was outside and unsupervised for approximately 22 minutes, during which time she traveled 0.4 miles away from the facility, down a busy four-lane street, and was eventually found in the parking lot of a local funeral home. The resident was dressed in a sweatshirt and jeans, and the temperature was 51 degrees Fahrenheit. Interviews with staff revealed that there was a lack of immediate response to the resident's absence, and the missing resident procedure was not initiated promptly. Staff failed to maintain awareness of the resident's movements near the exit, and the facility's wandering and missing resident procedures were not followed as required. The facility's policy required that residents at risk for elopement be identified, have preventative plans of care implemented, and receive visual supervision as necessary. In this incident, the resident was not identified as being at risk for elopement at the time, and staff did not provide the required supervision or intervention. The failure to follow established procedures and to provide adequate supervision resulted in the resident being placed in a situation likely to cause serious injury, harm, impairment, or death.
Removal Plan
- Initiated a search within the building and outside the parameters for Resident #9 upon notification of elopement.
- Administrator checked Resident #9's room and the front entrance.
- Social Service Director (SSD) and Physical Therapy Assistant (PTA) assisted in searching outside.
- Located Resident #9 in front of the funeral home, 0.4 miles from the facility.
- Ensured Resident #9 was safe and uninjured.
- SSD called Resident #9's Resident Representative (RR) and informed her of the incident.
- Printed census for North and South unit and completed a head count to ensure all residents were accounted for.
- Completed a body audit on Resident #9 by RN with no injuries noted.
- Reported the incident to the State Agency.
- Maintenance completed an audit on all doors and windows to ensure proper functioning.
- On-call Nurse Practitioner (NP) notified and new order for in-house psych evaluation given.
- Medical Director, Medical Doctor (MD), and NP #2 notified by Administrator of the incident.
- All staff in-services began on Elopement/Unsafe wandering plan and the Emergency Procedure - Missing Resident and Abuse and Neglect; completed by Assistant Director of Nursing (ADON).
- Conducted an Elopement Drill by Maintenance Director, completed on all shifts and to be continued weekly for four weeks and monthly for three months.
- Held an emergency Quality Assurance Performance Improvement (QAPI) meeting with IDT members to discuss the incident, actions to be taken, and further interventions.
- Reviewed policy with QAPI committee; no recommendations for change.
- Added Resident #9 to the wander book and provided a wander guard.
- Person-centered in-services to be completed with staff whenever any new residents are identified as an elopement risk.
- Elopement drill on all shifts and one elopement drill per week on alternating shifts for four weeks, then monthly for three months.
- Head count by census.
- Maintenance quality check on all doors and windows.
- SSD to complete 100% audits on all wanderers, update wander book, update care plans, in-service on wander book location, conduct interview with resident for any psychosocial harm.
- Updated Medication Administration Record (MAR) with hourly visual monitoring for Nursing by RN.
- Point of Care (POC) updated for hourly visual tasks for CNAs to mark complete by MDS Nurse.
- SSD conducted interview with resident to assess psychosocial harm.
- Placed Wander Guard bracelet on Resident #9's left wrist.
- Care plans updated by SSD.
- 100% audit done on all wanderers by SSD and Wander Book updated with photos and face sheets.
- 100% audit done by SSD on all Wander Guard bracelets to ensure appropriate functional ability.
- Maintenance Director to perform elopement drills on all shifts, continue for four weeks and monthly for three months, and bring results before the QAPI committee each month for review and recommendations.
- Any issues to be addressed immediately by the Administrator and the DON.
- Incident reported to the Attorney General's Office by Administrator.