A newly admitted resident was found wandering and was at risk for elopement; however, his elopement risk assessment had not been completed. Later that night, the same resident was found on the floor with a hematoma on his head, and had to be sent to the hospital for evaluation. At the hospital, the resident required a CT scan. Although he was considered a fall risk, a fall prevention care plan had not been developed.
Upon admission to the facility, the resident’s assessment should have been completed, identifying safety and care needs at a minimum. The facility’s admission policy should instruct staff at a minimum about which assessment(s) should be completed and what care plan topics should be put into place to provide safe, quality care. The new resident’s safety and care needs should clearly be communicated to the direct care staff. Safety assessments could include fall risk, behavior management, elopement risk, skin care measures, and code status (DNR vs CPR.) Care assessments could include ADLs, cognitive abilities, incontinence needs, and dietary/hydration needs. Additionally, a resident with special care needs should be clearly addressed through assessment and care planning. Each staff member should know his or her role when admitting a resident. It is the care team’s responsibility to provide safe and consistent care from the time the resident enters the facility and throughout their stay.
I. Risk Exposure:
A newly admitted resident was found wandering and was at risk for elopement. His elopement risk assessment was blank. At 11:15 PM he was found on the floor trying to get back into bed. He was also a fall risk and did not have a fall care plan put into place until after the fall. He sustained a hematoma to his head and was sent to the hospital for evaluation. A CT scan was negative.
II. Potential Reason:
On the day of admission the required assessments were not conducted and care plans were not implemented.
III. Mitigation Strategy:
An investigation was initiated. An elopement risk assessment was conducted and a wander guard bracelet was applied. Care plan interventions were implemented. A fall risk care plan will be implemented to include a toileting plan with three day tracking, floor mats, and a low bed. Family members will be asked to suggest activities that will be of interest to the resident.
IV. Potential F-Tags:
•F270- Care Planning
•F323- Accidents and Supervision
V. Performance Improvement/Education:
Falls, elopement, and code status must be determined at the time of admission. Consideration is being given to the development of mini-care plans that can be put into place at the time of admission to provide safety for at-risk residents.
