Incident report on residnet who went out door. Advice

Specialties Geriatric

Published

The other evening when I was working my evening shift as an LPN a resident went out an alarmed door in the dinning room .No staff where present at the time. The alarm sounded at the nurses station and the unit secretary sent staff to check it out. A confused resident from my unit had gone out looking to go home. . Another nurse working on a unit closer to the dinning room informed me of the incident. Two CAN's where able to redirect resident back into facility from what I was told. The CNA then brought the resident back to my unit .I immediately went to the unit manger on duty and informed her of incident and asked her how to get a wandergaurd for resident. She did not know and stated she will call our rehab nurse as the rehab nurse is the person who has our alarms. I also reported the incident to the nursing supervisor on duty a short time later. We discussed alarms and what doors have alarms along with the wandergaurd system . I was later informed by one of them that the dinning room door does not have a wandergaurd alarm. The only door having a wandergaurd system was the front door. I did not think of doing an incident report and both supervisors did not inform me to do so. So two days later on my day off I get a call from the ADON saying she is doing a VA report and asks me some questions. I informed her I had reported it immediately to my unit manager . She called me back a short time later and asked that I fill out incident report. I offer to come in and do it right away and she informs me I can do it the next day when I come to work. Again she asks me if I reported it to anyone. Again I tell her I informed the unit manger right after it happened. She states " Oh she is new "

So the next day when I get to work I fill out the incident report and then talked to my unit manager. She shares with me the internal investigation that the ADON has done. She informs me it is a learning experience for all of us. Here is what ADON has document in her report on me.

Team Leader- was notified of incident between 4-4:30pm. She did not do an incident report or called in the potential VA. She was educated that there needs to be documentation and VA called in, she was informed to notify the supervisor. She was told she needed to come in and complete the incident report.

So it looks like I did nothing. I am angry and feel I should talk to DON on this matter.

PS - Internal conclusion : This is not a VA as staff responded to door alarm.

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What is a VA?

If a resident leaves and no one sees them leave, then we do incidents. All of our doors except the front have alarms on them. They all lock with a wanderguard. Sometimes a person could slip thru a door and we are right behind them, then we don't do an incident.

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A VA is Vulnerable adult.

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Specializes in LTC, Memory loss, PDN.

How did you document in the resident's chart? I never mention the word incident report in the patient's chart, but I document when and how and who I informed of the event. Did you document your conversation with unit manager and supervisor?

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Specializes in LTC, Memory loss, PDN.

If you charted that you updated the unit manager and the supervisor, you have all the amunition you need to go to the DON or higher if necessarry. If you don't have good documentation, I would leave things alone and take it as a learning experience. When in doubt, always make out an incident report. Some states have time frames for reporting certain events. Always document when you give someone, other than direct care staff, an update on a patient.

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There is no need for any incident report unless a harm/injury is being done to the resident.

Anyhow, for your information, you must document the findings in the nurses notes. Plus, you also have to state that nursing supervisor was informed and issue was discussed. Also, what did you do after the "incident." This is an intervention. This will protect yourself from the state investigation should there is a harm/injury to that resident. The state want to see your intervention/action whenever there is a problem. Failure to act is a negligence; and a lawsuit is a possibility.

Good luck! And I don't think you will have to worry...

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Specializes in Gerontology, Med surg, Home Health.

I report EVERYTHING to the DPH, but I don't think I'd report this as an elopement. Your doors are alarmed. The alarm sounded and staff investigated. Found the resident immediately and escorted them inside. I would do an inhouse incident report, call the family and the doc, get a wanderguard on them, care plan for wandering and be done with it.

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Specializes in ICU, CM, Geriatrics, Management.
There is no need for any incident report unless a harm/injury is being done to the resident.

...

With respect, I must disagree with this notion. An incident isn't linked to actual harm.

Incident reporting is a tool to help us provide better care for our customers.

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Specializes in ICU, CM, Geriatrics, Management.
... I don't think I'd report this as an elopement...

From my experience, at most facilities, if they make it outside, it's deemed an elopement, unless they've been previously cleared to do so.

Moreover, in some cases, depending on the customer's status, if they leave the unit, it's considered an elopement.

Official medical status is key.

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With respect, I must disagree with this notion. An incident isn't linked to actual harm.

Incident reporting is a tool to help us provide better care for our customers.

I have already stated it!

What did she do when she encountered a problem and this is an intervention... The state knows the nurses are unable to prevent all the incidents/problems from happening; but they want to see the interventions done by the nurses.. What the nurses did to prevent similar problem from happening again! If the nurses are unable to solve the problem alone; then the state investigators want to see the collaboration between the health care teams regarding to this problem.

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Specializes in ICU, CM, Geriatrics, Management.

Hi, Fortune. Thanks for responding. Agree with your last post completely.

Your prior statement, which I believe is erroneous, is what I was addressing.

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Both of them are the same!

The second one I had to spend more time to define the first one!

What do you mean by "your prior statement...erroneous?" An incident report is not needed in this case due to the fact that there is no harm to the resident in this case! Reporting to the supervisor regarding to this "incident" is not the same as filling out an incident report! Did you read the bottom part of my 1st post right here?

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