Elopement Due to Inadequate Supervision and Identification Failures
Penalty
Summary
A cognitively impaired resident with a history of exit-seeking behaviors was able to elope from a secured unit due to inadequate supervision and failure to follow established identification protocols. The resident, who had diagnoses including dementia, depression, anxiety disorder, and altered mental status, was assessed as needing supervision for decision-making regarding wandering and elopement risk. Despite documented behaviors such as repeatedly asking to go home and inquiring about how to leave the facility, staff did not consistently reassess or update interventions after these behaviors were observed and reported. On the day of the incident, the resident was able to exit the secured unit after an LPN, unfamiliar with the resident and not given a report, asked a CNA to use her badge to open the locked door, mistakenly believing the resident was a visitor. Both staff members failed to check the posted pictures of residents at risk for elopement, which were intended to help staff identify and prevent such incidents. The resident, wearing an ID band, proceeded to the first-floor lobby and exited the building through the front door while carrying bags of clothing. The security guard at the front desk also failed to recognize the resident as a patient and did not intervene, only responding after being alerted by a visitor. Interviews and documentation revealed that staff on the unit, including the LPN and CNA involved, did not recognize the resident or utilize the available identification tools, such as the posted photographs and ID bands. Communication lapses were evident, as the LPN was not educated about the identification system and had not received a report on the resident. The facility's policy required staff to identify and intervene with residents at risk for elopement, but these procedures were not followed, resulting in the resident leaving the building unsupervised.
Removal Plan
- Resident was assessed post incident by Nursing Supervisor, placed on 1:1 monitoring for safety.
- A call was placed to the primary physician by the nursing supervisor.
- The nursing supervisor updated Resident's care plan.
- All staff were re-educated on the Elopement Policy.
- A new system was implemented that all visitors must sign out upon leaving the building.
- Security staff and receptionist staff were educated on the Elopement Policy and the new process for visitors signing out.
- All nursing staff were re-educated on identifying elopement behaviors and initiating and completing a new Elopement Assessment, updating the resident's care plan and placing the resident picture at the entrance of the unit, receptionist desk, and security console.
- An audit was completed on all residents who are an elopement risk to ensure they have an appropriate Care Plan, Elopement Assessment and resident picture at receptionist binder and security console.
- An audit was completed on all new admissions by the Infection Preventionist nurse and Nursing Supervisor to assure that residents identified at risk of elopement had an elopement care plan in place, ID band and picture on the wall of exit door and front reception desk and security desk.
- An audit was completed by the Nursing Supervisor on resident ID bands to ensure all residents had an ID band in place and that all resident pictures were present in Point Click Care as a form of identification. Refusal of pictures and/or ID band were indicated on the resident's care plan.
- The DON, ADON and ICP re-reviewed the Elopement Policy.
- The Nursing Supervisor and the ADONs completed the re-education on the Elopement Policy for staff.
- All unit doors continue to remain locked and continue to require a swipe ID card to get off all the Nursing Units.