Resident Elopement During Power Outage
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring systems were in place to prevent a resident from elopement during a power outage. A resident with mild cognitive impairment and a history of wandering eloped from the facility and was found approximately one mile away after being absent for about two hours. The facility's policy required an individualized care plan for residents at risk of elopement, and the resident had interventions such as routine checks and a wander guard. However, during the power outage, the door alarms were not connected to the generator, and the staff failed to notify Maintenance and the Leadership Team, which contributed to the resident's elopement. The incident occurred when the power went out at approximately 1:00 AM, and the staff performed headcounts at 2:00 AM and 3:30 AM, discovering the resident was missing. The staff called 911, and the resident was eventually found unharmed. Interviews revealed that the Director of Maintenance was not notified of the power outage, which was a procedural failure. The Administrator confirmed that staff should have called Maintenance and the Director of Nursing during the power outage and monitored emergency exits, but these actions were not taken.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 Preparation and/or execution of the “Plan of Correction” does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the “Statement of Deficiencies.” The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal Laws. 1. Resident #1 was found and brought back to facility safely and unharmed. Resident #1 was assessed by RN #1 and unharmed by incident and Resident #1 stated “he wanted to go for a walk outside.” Completion Date: 3/20/2024 2. All residents at risk for elopement or wandering behaviors were reviewed and accounted for to be safe and located in building during time of power outage incident on 3/20/2024. Completion Date: 3/20/2024 3. RN #1 was counseled on Elopement Policy and Procedure, Missing Resident Procedure, Loss of Power Procedure and Proper Notification and Wander Guard System. Administrator, Director of Nursing and Environmental Services Manager reviewed Policy and Procedure on Elopement/Missing Resident, Loss of Power Procedure and Emergency Preparedness Plan with no revisions needed. All staff were re-in-serviced and re-educated on the following: a. Elopement Policy and Procedure b. Missing Resident Procedure c. Loss of Power Procedure and Proper Notification d. Wander Guard System Completion Date: 2/17/2025 4. A Quality Assurance Audit was developed on residents at risk for eloping from facility during a power outage. Audits will be completed by Director of Nursing/Maintenance Manager monthly for 3 months and quarterly thereafter, with the results presented to the Quality Assurance committee for action, if needed. Completion Date: 3/31/2025