Resident Elopement Due to Inadequate Supervision and Elopement Risk Assessment
Penalty
Summary
A deficiency occurred when a resident with dementia, muscle weakness, and major depressive disorder was able to exit a secure, third-floor lockdown unit without staff knowledge. The resident's care plan identified them as at risk for falls and noted impaired cognitive function, but an elopement evaluation was inaccurately coded, failing to identify the resident as cognitively impaired or at risk for elopement. As a result, the resident was not care planned for elopement risk, and no additional supervision or interventions were implemented to prevent unauthorized exit. On the day of the incident, the resident was last seen in bed by staff and subsequently left the secure unit by following dietary staff into the elevator. The dietary staff did not recognize the resident as a resident, and the front desk receptionist, also failing to identify the individual as a resident due to their attire and lack of identification, allowed them to exit the facility. The absence of a process for signing out visitors further contributed to the failure to recognize the resident's departure. The facility only became aware of the resident's absence when a family member called to report that the resident had arrived at their home, which was 1.2 miles away and required crossing busy streets and high-traffic areas. The resident was missing for approximately two hours before being returned to the facility. This sequence of events demonstrated a lack of adequate supervision and failure to maintain a secure environment for residents at risk, resulting in an Immediate Jeopardy situation.
Removal Plan
- Resident was assessed by the nursing supervisor and no concerns were noted.
- Resident was provided with an anti-elopement device and was placed on a one-to-one observation by staff until seen by Geri-Psych Nurse Practitioner.
- Nurses reviewed or completed an elopement evaluation for all current residents.
- All residents who were deemed high risk for elopement were also provided with an anti-elopement device and care planned.
- Facility Elopement Policy was updated by Administration to include how the facility will identify residents who are at risk for elopement.
- New process was put in place for the front desk staff to oversee the completion of entrance logs for visitors and staff.
- Kitchen staff started a new process to not allow residents and visitors in facility elevators when in use for dietary functions.
- Elopement drills were completed.
- Facility staff were educated on the updated elopement process.
- Facility staff were educated prior to the start of their shifts with any per diem, part time, or agency staff education to occur before their next shift.
- Director of Nursing or designee will complete an audit of resident's charts to ensure residents who are at risk for elopement have an elopement evaluation completed. The audit will be conducted twice a week for 30 days.
- Results of the audit will be presented to the monthly QAPI committee for review.