Question

Now that you have learned how to conduct a Root Cause Analysis (RCA), please perform one for the following scenario in your role as Quality Director for a 300 bed Nursing Home in Manhattan:

Mr. Caring, a Nursing Home patient was identified at risk for elopement

They were given a wanderguard bracelet, which is connected to the front and stairwell doors

Resident has been at facility for 15 years, is alert and oriented x 2-3, smoker, walks a small amount of feet and usually sits in a wheelchair, which they propel.

The resident is on 30 minute safety checks

At 7:00 am on Monday, you are at the facility and informed that Mr. Caring's empty wheelchair ws found at the back door a few minutes prior.

Next steps.... do your root cause analysis to find out what happened and when you do, develop a corrective action plan tp prevent it from happening again.

There are different RCA formats available. Explore the templates and select one you are comfortable with. JCAHO has a very comprehensive template available.

Answer 1

Root cause analysis for Mr. Caring's elopement incident should focus on equipment functionality, staff adherence to procedures, and resident satisfaction with facility programs, leading to a corrective action plan that addresses these issues.

Step-by-step explanation:

Root cause analysis (RCA) for the elopement risk incident begins with gathering information from stakeholders including the front desk logs, security system data, and staff interviews. The fact that Mr. Caring's wheelchair was found at the back door, where his wanderguard bracelet should have alerted the staff, suggests a system failure. Therefore, the analysis should explore how and why this failure occurred. Possible causes might include malfunctioning wanderguard equipment, improper use of the wanderguard system, lack of staff training, or a breach in the security protocols.

Next, we look into the established checks and balances, such as the effectiveness of the 30-minute safety checks, and whether they were properly conducted. Since Mr. Caring is known to be alert and oriented, it also becomes important to consider the resident's own actions and motivations. This could suggest a limitation in social or recreational activities that might have influenced Mr. Caring's movements.

The RCA should result in a corrective action plan to prevent future incidents. This plan may include technical solutions like upgrading the wanderjahrs system, process adjustments such as revising safety check procedures, staff training on elopement risk and response, and reviewing and enhancing the facility's leisure and activity programs for residents.