Resident Elopement Due to Inadequate Supervision and Alarm Failure
Penalty
Summary
The facility failed to ensure a safe environment for Resident #154, who was severely cognitively impaired and at high risk for elopement. On 7/13/2024, the resident wandered off the 2nd floor Memory Care Unit without staff knowledge, exited through an emergency stairwell door that did not alarm, and left the building. The resident subsequently tripped and fell, sustaining a 2.5 cm laceration and hematoma to the head, as well as abrasions to the midback and right knee. This incident resulted in actual harm to the resident. The facility's policies on elopement and electronic wandering security were not adequately followed. Although the resident was identified as a high risk for elopement upon admission, the care plan did not initially include interventions for elopement risk. A wander alert bracelet was not applied until after the incident, and there was no evidence that the alarms were verified as functioning at the time of the elopement. Staff interviews revealed that no alarms were heard, and the facility did not have a properly fitting bracelet available immediately after the incident. The facility's response to the incident was delayed and inadequate. Staff were unaware of the resident's absence until a visitor found the resident outside and alerted the front desk. The resident was new to the facility, and there was a language barrier that complicated identification and communication. The facility's failure to apply a wander alert bracelet promptly and ensure functioning alarms contributed to the resident's unsupervised exit and subsequent injury.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? For Resident #154, the Elopement Risk Assessment was initiated on 7/12/24 and completed on 7/17/24. The care plan was revised on 7/15/2024 to reflect that the resident was at high risk for wandering and elopement related to impaired cognition and memory. Nursing interventions were outlined on the care plan. The resident was discharged from the facility on 7/24/24 to a lower level of care. Preventive Maintenance Checks were completed on all Doors, Locks, and Alarms by the Maintenance Staff on 7/6/24, 7/13/24, 7/20/24, and 7/27/24 and were documented as functioning. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The QA Committee met on 2/12/25, to complete an assessment of causative factors and to identify an appropriate plan to prevent recurrence. It was determined that all residents have the potential to be affected by the same deficient practice. The Nursing Unit Manager(s) will complete an elopement risk assessment on all residents to identify a baseline for every individual and will be completed by 2/21/25. Any resident who is identified at risk for elopement will have their care plan reviewed to ensure their risk is identified and that an adequate care plan has been developed to ensure the resident’s environment remains free from accident hazards, that adequate supervision and assistive devices to prevent accidents are in place at that time. Preventive Maintenance Checks were completed on all Doors, Locks, and Alarms by the Maintenance Staff on 2/1/25 and 2/8/25 and were documented as functioning. All egress doors are equipped with functioning alarming devices that are easily audible by all staff in all areas of the unit, including when in a room with a closed door. The Unit Clerks will verify that all current residents have a facility issued wristband placed on their person and that hospital identification bands are removed by 2/21/25. The Administrator verified that an appropriate amount of well-fitting wander alert devices were available in the event any residents were to require this type of intervention on 2/12/25. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? To ensure that the residents’ environment remains free from accident hazards and that adequate supervision and assistive devices to prevent accidents are provided, the following measures will be implemented: All licensed nurses will be re-educated on the facility’s policies titled Elopement Risk Assessment, Electronic Wandering Security System, and Guidelines for Care Planning Wandering/Elopement High Risk Residents that outlines when elopement risk assessments are to be completed, when appropriate safety measures are to be implemented, and documented on the care plan once risk level for unsafe wandering/elopement is identified. The facility’s policy titled Preventative Maintenance Program was reviewed and remains appropriate. Maintenance Staff will be re-educated on the policy and the required weekly functionality verification of egress door alarms and door security devices. The Front Desk Receptionists, Unit Clerks, and Medical Records staff will be educated on the facility’s policy titled Resident Identification / Patient Identifiers and their responsibility of placing facility identification wrist bands upon admission to the facility to ensure residents are adequately identified in emergency situations. The facility’s assessment and minimum staffing plan will be reviewed and/or revised by the facility administrator to ensure adequate supervision and to prevent accidents. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The Director of Nursing / designee will conduct an audit of all new admissions within 24 hours of admission x 2 weeks, then weekly x 2 weeks, then monthly for a period of 2 months, to ensure Elopement risk assessments are completed as required, that appropriate safety measures have been implemented, that care plans are updated to reflect high risk residents, and that wander guard ankle bracelets have been placed when deemed necessary for residents at high risk. The Administrator, in conjunction with Maintenance staff, will conduct a monthly audit x 3 months ensuring that egress door alarms and door security devices have been checked weekly through the Preventive Maintenance Program and that are all functioning as intended. The Unit Clerks will conduct a weekly audit of all new admissions x 4 weeks, then monthly for a period of 3 months, to ensure facility identification bands are present and hospital identification bands removed for all new admissions/readmissions. The Director of Nursing will review daily staffing schedules weekly x 4 weeks, and then monthly for a period of 3 months, to ensure minimum staffing is in place to provide adequate supervision to prevent accidents. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on 3/7/25.