Failure to Supervise and Accurately Assess Elopement Risk Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to a resident who was inaccurately assessed as low risk for elopement, despite having diagnoses including Parkinson's disease with dyskinesia, neurocognitive disorder with Lewy bodies, muscle weakness, and difficulty walking. The resident's admission assessment incorrectly indicated no dementia, resulting in a low-risk classification for wandering, even though the Minimum Data Set (MDS) showed moderate cognitive impairment. Multiple staff members observed the resident exhibiting exit-seeking behaviors, such as attempting to use the elevator, but none reported these behaviors to their supervisors. On the day of the incident, the resident was seen several times by different staff members attempting to access the elevator and was redirected to their room each time. However, these repeated exit-seeking behaviors were not communicated to supervisory staff. Later, the resident was observed by a staff member leaving the facility but was mistakenly believed to be on a leave of absence. The staff member did not report this observation, and the resident subsequently exited the building and walked out of the facility. The facility only became aware that the resident was missing when the resident's daughter called to report that the resident had arrived at her home after crossing multiple busy streets. The facility's failure to accurately assess the resident's elopement risk and to provide appropriate supervision for a resident actively exhibiting exit-seeking behaviors resulted in the resident leaving the facility without staff knowledge.
Removal Plan
- Nursing Administration reviewed all residents' electronic health records for accurate elopement/wandering evaluations.
- Elopement books at the reception desk and every unit were reviewed to ensure all residents identified as elopement risks were current and resident identifiers were available.
- Sign posted at reception notifying visitors of the Leave of Absence (LOA) process.
- Staff educated on routine resident checks, the wandering and elopement policy, and the wander management and elopement prevention policy.
- RN Supervisors/Unit managers educated on the completion of headcounts of all residents compared to the midnight census and the immediate reporting of any discrepancy to the Director of Nursing (DON).
- Staff educated on the LOA process.
- Reception staff educated on the facility visitor badge protocol, visitor badge process, resident leaves of absence, and signing residents out.
- Staff educated on the elopement/missing person policy and procedure including the elopement code announcement to notify staff in the center, search on the premises and the surrounding areas, and notification processes.
- Staff educated on elopement drills including the frequency of drills and expected responses.
- Training regarding elopement added to the general orientation schedule for new employees.
- Elopement drill completed.
- Elevator and keypads assessed. Elevator keypad code changed. Additional training provided to staff related to not providing keypad codes to visitors and/or residents.
- Elopement/wandering evaluation updated as needed.