Failure to Prevent Elopement Due to Inadequate Supervision and Lapses in Safety Protocols
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as high risk for elopement, resulting in the resident leaving the facility without staff knowledge. The resident, who had a history of cognitive impairment, poor decision-making skills, and demonstrated exit-seeking behavior, was assessed as an elopement risk and had interventions in place, including placement on a secure unit with a wander guard and scheduled 15-minute checks. Despite these interventions, the resident was last seen in the dining room and was later found missing during medication rounds. Staff statements indicated that the resident was observed in the dining room and walking the unit, but there were gaps in supervision and incomplete documentation of required safety checks. The resident was able to exit the unit by accessing the elevator after learning the code, which was reportedly spoken aloud by staff. The resident then left the building and was located by police approximately 600 yards from the facility. Documentation revealed that the required 15-minute safety checks were incomplete or missing for several days, including the day of the elopement, and staff were unable to account for the resident during routine checks. The resident later stated that he was able to leave because he knew the elevator code and expressed a desire to leave the facility. Interviews with staff and review of facility records confirmed that the facility did not maintain adequate supervision or ensure the effectiveness of elopement prevention measures for this high-risk resident. The failure to consistently perform and document safety checks, as well as to secure the elevator code, directly contributed to the resident's ability to elope. This incident created an immediate jeopardy situation for the resident, as confirmed by the Director of Nursing and survey findings.
Removal Plan
- R3 was assessed for injury.
- Physician orders were reviewed, and plan of care was updated.
- R3's care plan was updated to include a change from Q 15-minute checks to 1:1 observation based on length of time needed to exit unit.
- Family and provider were notified.
- A root cause analysis was conducted.
- Maintenance changed elevator code.
- All stairwell doors and exterior doors were checked to ensure functionality with no issues identified.
- Education on facility elopement policy, notifying maintenance if a resident learns the elevator code, and making sure stairwell doors are closed and locked after use was implemented.
- QAPI meeting was held to review root cause analysis and elopement policy.
- Director of Nursing confirmed that R3 elopement risk assessment correctly identified him as an elopement risk and was up to date.
- Elopement risk assessments were reviewed and confirmed up to date and accurate for all residents.
- For residents assessed to be at risk for elopement, care plans were confirmed to include interventions to minimize risk of successful elopement.
- All staff were confirmed to have received elopement education.
- Director of Nursing will audit all admissions/readmissions to ensure elopement risk assessment is completed and residents at risk of elopement have interventions listed in their care plan to reduce the risk of successful elopement.