Long-Term Care Survey Alert

10 ways to keep IJ at bay

If a resident "exits" undetected, your facility will likely be unable to exit an IJ citation - unless staff followed a best practices elopement prevention and response plan.

"Elopement has become a hot button issue since the Centers for Medicare & Medicaid Services essentially directed state agencies to automatically presume it's an immediate jeopardy situation," says attorney Matthew Murer, with Schiff Hardin & Waite LLP in Chicago. Yet courts have ruled that exiting or elopement is not necessarily a deficiency, if it was unforeseeable, he notes. "And some things are unforeseeable - for example, the wander guard system malfunctions and/or a resident exits who has never displayed that type of behavior or tendency in the past," Murer says.

Even so, facilities will have to jump through hoops to prove to surveyors or at IDR or appeal that they covered all the bases in preventing and managing a resident elopement. Following these 10 strategies should help you make a solid case, should you have to prove yourself:

1. Implement careful assessment protocols to determine each resident's ongoing risk of exiting. Cognitive impairment and a previous elopement history pose the biggest known risk factors. "Ask family members and/or caregivers at the resident's previous placements if he had a tendency to wander or try to leave the premises," suggests Jim Schuster, an attorney with the Council for Regulatory Compliance in Cincinnati and Washington, DC.

Re-evaluate risk when a resident's condition deteriorates or improves - or if the resident is unusually agitated, advises Joseph Bianculli, an attorney in Arlington, VA. "For example, if the resident has to get up to use the bathroom three times a night because of a UTI, he may be more at risk of elopement during that time," Bianculli notes. Residents who are in transition - ither new to a unit or facility or readmitted after a hospitalization - are also at higher risk of elopement, cautions Dave Meek RN, CEN CLNC, founder of the National Institute for Elopement Prevention and Resolution in Topeka, KS.

2. Develop, implement and revise care plans as needed for residents at risk of eloping. Include individualized interventions based on risk assessments. "Many facilities make rounds to make sure residents are accounted for every couple of hours, but you may need to make more frequent checks for residents at risk for wandering," advises Schuster.

Re-evaluate the care plan each time the resident attempts to exit the facility or care environment. "Try to figure out the cause and effect of the elopement and address those," Schuster counsels (see, "5 Reasons Why Residents Attempt to Elope", this issue.).

Consider obtaining a psychiatric or psychological assessment and expert recommendations for how to prevent further incidents of exiting. "Then follow those recommendations" and document that you did, Schuster advises. "That way, if the resident does elope and the facility challenges a deficiency, the outside consultant can testify that the facility did everything possible to avoid the elopement."

Smart Idea: Post pictures and names of potential "elopers" at the nurses station and front reception desk, suggests Beth Alford, RN, principal of Professional Liability Insurance Services in Belton, MO. "This enables staff to readily identify residents and be extra vigilant should they see them going outside."

3. Implement appropriate facility-wide elopement-prevention policies and procedures that all staff understand and follow. Specify maintenance checks for windows, alarms, doors, etc. But make sure your policy is realistic, advises Murer. Otherwise, staff won't be able to follow it, and the plan then turns into a liability trap.

Warning: "If the alarms fail and a resident elopes, the first thing investigators will ask to see is the maintenance log documenting the last time anyone checked to see the alarm was working," cautions Meek.

Review the policies and procedures periodically to address changes in resident census characteristics, advises Schuster. Also make sure staff routinely document that they are following the facility's policies and procedures. "In a recent elopement case, CMS critiqued lack of documentation of two-hour checks," Bianculli warns.

4. Make sure your alarm system actually alerts staff. Staff's failure to pay attention to alarms is the most common cause of elopements, in Alford's view. "Door alarms are vital but only effective when staff become 'alarmed' to hear them and run to the door," she notes.

To keep staff on their toes, conduct practice alarm drills. "Set off a door alarm and see how the staff responds and if they follow the facility's policies and procedures," Alford suggests.

 5. Beware power outages when using coded entry systems. These systems - which require staff to punch in numbers to get in and out of a unit - don't work during power outages, Meek notes. So if you're going to use them, make sure to put them on your emergency generator systems, he advises. Otherwise, residents may slip out during a storm when the power is out. "And exposure is what most often hurts or kills residents who elope," Meek cautions. Also, storms tend to agitate and frighten residents, so they are more likely to try to exit at such times.

6. Identify and address specific hazards unique to your facility's location and grounds. For example, does your facility need protective fencing to prevent residents from wandering to nearby busy highways, water or construction sites? "CMS also seems to critique (albeit after the fact) failure to install relatively cheap things like more outdoor lights," Bianculli cautions.

7. Never underestimate a cognitively impaired resident's ability to exit the facility or care environment. For example, a resident with dementia can watch and remember the pattern of numbers staff punch into keypads to leave the unit every shift, Meek notes. "Or they may shadow someone and go out when that person does," he cautions. "One resident learned that if she lifted her wander guard above the sensor, she could exit without triggering the alarm."

8. Develop a practical and thorough elopement response plan. Without a plan, staff may get caught up in the heat of the moment and fail to search in a systematic way, Meek cautions "Or they may leave other residents unattended during the search," he adds. "And that can really come back to haunt the facility ... if something else happens to a resident during the search."

Staff doing the search should know to thoroughly comb every part of the facility and look in parked cars outside, behind bushes and up against the building. Meek is aware of one resident discovered after three days under a pile of linen within the facility. "Luckily, he was OK, but discovering a resident in the building like that is one of the worst case scenarios from a liability perspective, because it shows the facility didn't search adequately," he says.

Don't Be Fooled: When doing searches, don't assume that a resident couldn't be in a locked area. "Today's generation of residents coming into facilities are used to always locking the door once they enter their homes," Meek notes.

Include specific procedures identifying whom to contact in the case of a suspected or confirmed elopement. "Call the police if a search of the building and grounds does not find the resident," advises Alford.

Be Proactive: Check with the local sheriff or Alzheimer's Association about tracking systems that can help recover wanderers quickly, Bianculli suggests.

9. Conduct regular elopement drills. "Hide" a resident in an office and have the staff take it from there in doing head counts, searching the building and grounds and immediate neighborhood, Alford suggests.

10. If a resident exits, don't hang the facility with inappropriate documentation. "Too often providers document speculation about how an elopement occurred," Murer cautions. "But documentation should not be a laundry list of things that staff may have done wrong," he emphasizes. "Instead, emphasize the steps staff took to address the situation. Stress the timeliness and the thoroughness of your efforts."