Failure to Prevent Elopement of Cognitively Impaired Residents Due to Ineffective Supervision and Alarm Systems
Penalty
Summary
The facility administration failed to utilize its resources effectively to ensure the safety of three cognitively impaired residents, resulting in multiple incidents of unsafe wandering and elopement. One resident with severe cognitive impairment and a wander alarm bracelet exited the facility without appropriate staff response to the door alarm and was found unsupervised in the parking lot by a staff member on break. Another resident, also with severe cognitive impairment and a wander alarm bracelet, exited the facility without staff knowledge and was found wandering in the parking lot by a visitor, who then notified the DON. A third resident, who was mobile and had severe cognitive impairment but was not initially identified as an elopement risk, exited the facility unsupervised and was found outside by a staff member leaving work. The facility's investigations revealed that staff did not respond appropriately to door alarms, and in some cases, were unaware that residents had exited the building. The facility's elopement prevention policy required functional alarm systems and staff education, but observations showed that alarms were not always audible at the nurse's station and that staff did not consistently respond to them. Additionally, the front entrance door locked when a wander alert bracelet was detected but did not have an audible alarm, and staff were not aware of this deficiency. The Maintenance Director confirmed that issues with the doors had been ongoing and that elopements typically occurred through the front door, which lacked an effective alert system. Interviews with the Administrator and DON indicated a lack of awareness regarding the functionality of the entry doors and the potential for residents to exit undetected, especially by following others through already opened doors. The Administrator, new to the facility, acknowledged that she was still learning about the systems in place and had not made significant changes to door security beyond discussing possible upgrades. The facility's failure to ensure effective supervision and functional alarm systems for residents at risk of elopement led to the determination of Immediate Jeopardy.