In last week’s post, CMSCG explored high-risk events that, in many instances, lead to higher scope/severity deficiencies or, if you are lucky enough to have time to fully implement a corrective action plan for the event, a past non-compliance citation. The problem with these high-risk events is that the occurrence has the potential to be an IJ situation in the making or has resulted in actual harm to a resident, making the event reportable. So, when your “reportable event” gets submitted to the state, you may not have sufficient time to fully implement a plan of correction before you have a visit from surveyors.
Looking at a few examples of IJ situations related to F689 and elopement citations really highlights the importance of having strong accident prevention systems in place for different types of occurrences including high-profile events such as elopements. A strong elopement prevention system is necessary and should be coupled with well-educated staff who know exactly what to do in an elopement situation. Staff need to be provided with necessary training so that they are knowledgeable about what actions to take and in the correct order to implement them. They know better than to just shut off an alarm. If you did not look at CMSCG’s series on IJs across the States, you should take a peek. There was an unacceptable number of events reviewed that were enlightening related to understanding that an elopement was triggered by staff not following established protocols that ended with a catastrophic outcome for a resident.
A strong elopement prevention system is necessary and should be coupled with well-educated staff who know exactly what to do in an elopement situation. Staff need to be provided with necessary training so that they are knowledgeable about what actions to take and in the correct order to implement them.
Staff not adhering to elopement prevention protocols is well highlighted in citations that I’ve personally been involved in over the years. How do you forget an event where staff simply looked out the window on the door to the roof when the door alarm sounded and did not see anyone, so just turned off the alarm. Unfortunately, a resident was on that roof, hidden from sight and the decision not to go out on the roof on that rainy, cold night to conduct a full check of the roof resulted in a resident’s death. Inclement weather should not affect a staff member carrying out their responsibilities when an alarm sounds.
Security staff employed by a facility or who work for a security agency assigned to a facility have a great deal of responsibility related to elopement prevention – they literally are the keeper of the gate. I still have difficulty understanding how a security guard who hears the front door alarm sound merely turns the alarm off and doesn’t check the area where the alarm sounded. The guard doesn’t even need to leave his or her chair in some facilities to shut off the alarm. A guard simply shutting off the alarm has resulted in too many elopements. There should never be an instance when a resident (who does not “look” like a resident) is able to get dressed in their street clothes and coat and is able to exit the building amid a large group of visitors exiting the building. How about the guard who shuts off the alarm while a group of residents are in the lobby area for an activity and a resident with a security device exits the building and falls in the driveway sustaining a head injury? Thank goodness for the conscientious visitor who reported to the security guard that someone was lying in the driveway.
These are just two more examples as to how an elopement prevention system can fail. Neither one of the examples are hard to envision happening – just think of your own resident population. What about a resident, who has a focused desire to leave, and staff are aware of the exit-seeking behavior, but the resident manages to exit the building by quickly entering a stairwell behind a physician and exits the building via a side door? Before this elopement, the staff were aware that they were to stay and ensure that the alarm was reengaged, but the hurried physician did not follow established protocol. You can understand why the Centers for Medicare & Medicaid Services (CMS) defines some accidents as “avoidable” in Appendix PP – these type of situations are avoidable so long as staff follow your safety protocols. Train them, do drills and educate them some more.
We all want our residents to participate in religious services of their choice, so how did a confused gentleman who needed to be escorted to the service, manage to exit the building and walk to his home blocks – from the facility? Do you think that his elopement risk assessment was accurate? Obviously, the staff planning to get him to the religious service didn’t close the loop and arrange for him to get back to his unit supervised. Even just this handful of actual occurrences should have you thinking about scenarios that could occur in your building – and planning for prevention.
We’ve focused on staff failures to follow the plan but remember that there are also equipment failures that also can contribute to an elopement. Think about exterior door alarms, stairwell alarms, elevator alarms, personal security devices and how failures in these areas many times also contribute to elopement incidents.
Elopement prevention systems need to be comprehensive with ongoing monitoring of staff knowledge of the system and compliance with facility practices and individual resident prevention plans. You should have a plan for conducting elopement drills at different times on all shifts and using different scenarios and assess how your staff reacts. Remember, you never want to be the facility where a resident elopes and is never found.
If these scenarios raise concerns about your own elopement‑prevention systems, CMS Compliance Group can help. Our consultants work with facilities to strengthen protocols, train staff, and reduce the risk of high‑severity F689 citations. Contact us to discuss how we can support your team.
