Compliance Perspective – Suspends:
The Compliance Officer should review the facility’s policies and procedures with the Administrator, the DON and the Compliance Committee to ensure that the policies are in place to proactively assess for residents’ potential elopement. This process must include assessment of all residents for risk of elopement at admission and at regular intervals. The process needs to address safety protocols that are in place to prevent breeches in the alarm and warning systems on an ongoing basis and the procedures to take when a breech occurs. Staff should be trained on every aspect of the facility’s elopement policy and procedure, including what to do to ensure the safety of resident who are at risk of elopement during an emergency. Staff training must also include elopement drills along with education about the use and periodic updating of the Elopement Book. The Compliance Officer will ask the Don to develop and implement an audit to assess and evaluate all residents for their risk of elopement at regular intervals. The DON will review assessment changes with the nursing staff to determine how to respond, e.g., WanderGuard® bracelets, increased monitoring, etc. The DON will also be asked to develop and implement an audit to determine the success of the elopement drills and the need for additional drills dependent upon the staffs’ competency in completing the drills.
Violations involving the “administration, performance improvement and nursing services” of a Tennessee nursing home have caused the State’s department of health to suspend new admissions into the facility effective August 11, 2018, and to impose a total of $6,000 in civil monetary penalties for 4 separate assessments.
The complaint that launched the investigation involved a resident with dementia who was able to walk unaccompanied and leave the facility through its main entrance. The resident was wearing a WanderGuard® bracelet that triggered an alarm, but the man exited at the same time as a group of contracted landscapers. The receptionist in the area reported that she heard the alarm and that she got up and walked around and looked out but did not exit the building because she did not see anyone outside. She then re-set the alarm and went back to her desk.
One of the landscapers returned to the reception area and reported that a resident had left the facility and had fallen down an embankment into the woods.
The Health Commissioner’s report stated that the incident was an “avoidable accident,” The cognitively impaired resident was recognized as having the potential to wander and was wearing a WanderGuard® that functioned as it should by sounding an alarm, yet the resident was able to leave the facility. He fell down an embankment and injured himself.
The State Health Department investigators determined that the nursing home’s “administrator failed to ensure all employees and contractors were trained/in-serviced on the supervision of residents at risk for elopement, failed to ensure that staff properly responded to the WanderGuard® alarm when the resident eloped, and failed to follow facility policy to protect the safety and well-being of the residents.”
