Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known history of dementia and wandering exited the facility without adequate supervision. The resident had been assessed as an elopement risk, with interventions in place such as a wander guard device and inclusion in the facility's elopement risk program. Despite these measures, the resident was able to leave the second-floor nursing unit, access the elevator, and exit through the ground floor loading dock door without triggering any alarms or being stopped by staff. The wander guard system did not have sensors on the elevators or stairwells, and staff were unaware of this gap in coverage. Multiple staff members observed the resident ambulating the unit and attempting to access doors and elevators, but there was no order for frequent checks, and staff did not consistently monitor the resident's whereabouts. The resident was last seen around dinner time, and after refusing dinner, was assumed by staff to be elsewhere on the unit. The resident was observed on security footage exiting the building in the early evening, but the absence was not discovered until several hours later. The facility's elopement protocol, including a code yellow and a building search, was not initiated until approximately four hours after the resident had left the premises. The resident was found by local law enforcement approximately 1.5 miles away from the facility in sub-freezing temperatures and was admitted to the hospital with hypothermia. The resident was unable to identify themselves and required fingerprinting for identification. The delay in recognizing the resident's absence and the lack of effective monitoring and alarm coverage directly contributed to the resident's elopement and subsequent harm.
Removal Plan
- Code Yellow-Responding to Elopement was called by the nursing supervisor.
- Elopement protocol initiated and whole building and outside perimeter was searched.
- All other residents were verified as being present through a whole house bed check, and the police/911 and physician were called.
- Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified that Resident R223 was missing.
- Ground level door audits and wander guard system audit was completed by NHA to ensure proper function.
- Police notified NHA that Resident R223 was located at the local hospital.
- NHA and nurse aide verified Resident R223's identity at the local hospital.
- It was determined that Resident R223 was picked up by Emergency Medical Services (EMS) about 1.2 miles from the facility and taken to the local hospital.
- An ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held with department heads.
- Whole house wander guard audit was completed to verify placement and function for residents assessed as needing one.
- Whole house elopement assessments completed with no new residents identified as being at risk for elopement.
- Elopement binder reviewed and audited to ensure book is up to date and current with completion of new assessments.
- Every 1-hour loading dock door checks initiated and are ongoing.
- Facility contacted wander guard service provider to obtain quotes to add wander guard sensors to elevators, stairwells, and service hallways.
- It was determined that the resident exited out of the loading dock doors.
- Frequency of loading dock door check increased to every 30-minutes.
- Education on Code Yellow-Responding to Elopement initiated with in-house nursing staff.
- Elopement policy reviewed.
- Education initiated with all facility staff on signs and symptoms of elopement and supervision of residents with dementia and history of exit seeking behaviors, how to identify residents and where wander guard sensors are located within the facility.
- This education will be added to new hire orientation.
- 85% of facility staff will be educated.
- Facility is completing loading dock and front entrance door audits every 30 minutes daily for 30 days.
- Facility will review findings of audits during QAPI meeting.
- Resident R223 at hospital and will be re-assessed upon re-admission.