Failure to Prevent and Respond to Resident Elopement
Penalty
Summary
The facility failed to implement sufficient monitoring interventions and supervision to prevent an elopement incident involving a resident with a known high risk for wandering. The resident, who had diagnoses including dementia, Parkinson's disease, and anxiety, was assessed as high risk for elopement and had a documented history of wandering behaviors. Despite these risk factors, the resident was able to exit the secured dementia unit and was found walking alone in the facility's parking lot. There was no documentation in the clinical record regarding the elopement on the day it occurred, and the resident's care plan was not updated to reflect the incident or address the increased risk. Staff interviews revealed a lack of awareness and inconsistent accounts regarding the event, with some staff believing the incident was an elopement drill and others unaware of any such drill or actual elopement. Key staff, including the DON and NHA, were not present at the time of the incident and were unaware of the event until after their return. Maintenance and housekeeping staff were not asked to check door locks or alarms following the incident, and several staff members who responded to the alarm were not asked to complete incident reports or provide documentation of their involvement. Video footage confirmed that the resident exited the building alone and was outside for several minutes before being returned by staff. The facility did not follow its own policies regarding elopement response, which required examination of the resident for injuries, notification of the attending physician and legal representative, completion of an incident report, and documentation in the medical record. There was no evidence that these steps were taken following the incident. The lack of immediate investigation, failure to update care plans, and absence of required documentation and notifications contributed to the deficiency and resulted in the identification of Immediate Jeopardy for resident safety and supervision.
Removal Plan
- All secured exit doors are checked and confirmed to be fully operational. Secured doors may not be propped open for any reason. This expectation is communicated to all departments, including housekeeping and maintenance.
- The resident involved and all residents residing on the secured unit are reassessed for elopement risk, and care plans are reviewed and updated as indicated. A head-to-toe skin assessment is completed on the resident involved. Any resident identified as high risk is subject to hourly documented supervision, with continued monitoring based on reassessment.
- The facility implements hourly documented checks following any cleaning, construction, or maintenance activity involving secured exits to ensure doors remain secured and alarms are active.
- All in-house staff are educated on the facility's elopement policy, elopement prevention, door alarm response expectations, supervision requirements, and escalation procedures for any alarm activation involving secured exits. All remaining staff are educated prior to the start of their next scheduled shift until one hundred percent of staff education is completed. Any staff member on vacation or otherwise unavailable in person is educated by telephone. No staff member is permitted to work until education has been completed. Compliance is monitored.
- Elopement risk mitigation is monitored through daily review of door alarm functionality, alarm response, and supervision compliance. Any identified concerns are addressed.