In this annual/extended survey and complaint investigation, the facility failed to provide adequate supervision to prevent four of six sampled residents assessed as being at risk of elopement from successfully exiting the facility without staff knowledge. This resulted in Immediate Jeopardy when four residents eloped from the facility and the likelihood of harm for the additional 65 residents identified for elopement risk. On 01/08/10 and on 01/22/10, the administrator and director of nursing (DON) were notified that Immediate Jeopardy (IJ) began on 04/18/09 when Resident eloped from the facility after he gained access to the security code by watching as it was entered into a keypad. Immediate Jeopardy remains ongoing because the facility failed to provide adequate supervision to prevent residents identified as being at high risk of elopement from leaving the facility without staff knowledge. Facility was cited at a K level.
What actions would you and your staff members take to prevent this from occurring in your facility?
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Could this happen at your facility?
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Share your thoughts and ideas about our monthly Challenge Scenarios (based on real life examples) with a collaborative community dedicated to improving care.
Comments/Recommendations:
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2. Doors in resident rooms or apartments may present a problem with local fire departments as they may view securing them to prevent elopements as restricting means of egress.
3. Remember that “alarms” and delayed locking doors don’t stop residents from exiting, but may only slow them down somewhat and serve to alert staff to a departure
4. The fact that this resident never stopped talking about and attempting to leave would seem to indicate a need for additional attention in terms of supervision; and perhaps psychosocial, psychological or psychiatric evaluations and interventions.
5. Training staff in the importance of reporting escalating behaviors is also important in such cases.
6. Providers need to check their alarm system frequently to be sure they are in working order. Include the alarm system checks as part of your quality improvement program.
7. Regularly occurring missing resident / elopement drills are recommended, including after dark.
Elopement was also featured in the latest issue of Embrace the magazine. Get an overview of the article online at http://www.embracethemagazine.com/articles.asp?pg=4
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