Resident Elopement Due to Inadequate Supervision and Security Override
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as an elopement risk, resulting in the resident leaving the facility without permission. The resident, who had a history of attempts to leave the facility unattended and was diagnosed with dementia and a psychotic disorder, was equipped with a security bracelet designed to alert staff if they left a safe area. Despite this precaution, the resident was able to exit the building when a staff member used an identification badge to override the security system and open the door for visitors. On the day of the incident, the resident was observed on camera leaving the third floor and entering the lobby, where they followed visitors towards the exit. The visitors, unaware of the resident's status, did not inform staff that the resident was not with them. A dietary supervisor, believing the resident was part of the visitor group, used their badge to open the door, allowing the resident to exit. The security system alarm was triggered, but the resident had already crossed the threshold and was found outside in the parking lot by staff. Interviews with staff revealed that the security system was functioning correctly, but the use of an identification badge to open the door bypassed the alarm system. The facility's failure to properly identify the resident as a resident and not a visitor, combined with the staff's actions in overriding the security system, led to the resident's unsupervised exit from the facility. The incident was confirmed by the Director of Nursing, who acknowledged the lapse in supervision and identification procedures.
Plan Of Correction
1. The facility increased visual monitoring of Resident R1 and assigned staff to monitor for all residents including R1 usage of elevator during the times of reception employee vacancy. 2. All residents in the facility were reassessed for wandering and elopement risk. Resident care plans were reviewed and updated as needed. Security bracelet list was reviewed. 3. All facility staff are educated by Director of Nursing/Designee on elopement, security bracelet function, behaviors, and how to identify a resident exiting unaccompanied. 4. The Director of Nursing/designee will audit all residents with identified exit seeking behaviors for exit seeking behaviors relating to elevator use daily.