A Maine nursing home with a history of federal fines was listed as a special focus facility (SFF) after two residents wandered off in separate incidents last year. In the second case, the resident was hit and killed by a motor vehicle. The Centers for Medicare & Medicaid Services (CMS) created the SFF program to address the issue of facilities that fail to correct underlying systemic problems that give rise to repeated cycles of serious deficiencies, which pose risks to residents’ health and safety.
According to a Department of Health and Human Services report, on November 12, 2021, police found Resident #1 wandering along the side of the road with a walker. It was a rainy night, and the resident was wearing dark clothing and socks, but no shoes. The resident was confused and told police she was going to the store. They were one mile from the nursing home, so police took her to the facility. According to the police, the staff had no idea Resident #1 was missing or how long she had been gone.
According to a surveyor’s report after the incident, staff on duty had identified that Resident #1 was exit seeking and at risk for elopement, but had not intervened or taken actions to prevent her from leaving. The facility was fined $109,600.
A few weeks later, on the evening of December 6, Resident #2 wandered off, and was struck and killed by a motor vehicle. Police received a call from the driver of the vehicle who stated that they had hit and killed a woman standing in the road. The police officer who responded saw that Resident #2 was wearing an ankle monitor with facility information on it. The officer went to the facility and asked if all the residents were there. Staff assured the officer that all were there. The officer told them to check. After staff checked, they realized Resident #2 was missing.
Resident #2 had a history of wandering and wore a wander guard monitor that was supposed to sound an alarm and cause the front door to lock if she tried to leave. Staff said that no alarm sounded that night. A company later checked the system and found it was functioning properly. Surveyors interviewed the maintenance director of the facility who said that only facility employees received elopement/missing person training at orientation. He said agency staff did not receive that training. When asked, he stated that there had been no training for facility or agency staff on how the wander guard system works.
The facility’s failure to provide supervision to residents constituted an immediate jeopardy situation, and triggered an extended survey. Following the survey, the facility was also cited for failing to have a written transfer agreement with a local hospital, and failing to ensure staff members completed training on abuse, neglect, exploitation and misappropriation of resident property, and dementia care. The incidents contributed to the decision by regulators to list the nursing home as a special focus facility. The decision was based on a “persistent pattern of poor quality on a facility’s last three standard surveys and complaints,” rather than a single event.
Issue:
While wander, door, or building alarms can help to monitor a resident’s activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision, and require scheduled maintenance and testing to ensure proper functioning. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Facility policies that clearly define the mechanisms and procedures for assessing or identifying, monitoring, and managing residents at risk for elopement can help to minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision. In addition, the resident at risk should have interventions in their comprehensive plan of care to address the potential for elopement. Furthermore, a facility’s disaster and emergency preparedness plan should include a plan to locate a missing resident.
Discussion Points:
- Review policies and procedures for ensuring provision of adequate monitoring, sufficient staffing, and that there is adequate security to prevent residents from wandering away from the facility.
- Train all staff regarding abuse and neglect and the importance of providing adequate monitoring and care for the residents. Conduct elopement drills to ensure all staff on all shifts know how to competently respond.
- Periodically audit to ensure that residents’ elopement risk assessments are completed at the time of admission and updated periodically and as needed, and that staff are performing assigned checks of residents. Review care plans for residents identified at risk for elopement to ensure appropriate interventions are present and implemented.
