Unsupervised Elopement of Cognitively Impaired Resident Due to Lapses in Supervision and Environmental Security
Penalty
Summary
A cognitively impaired, ambulatory resident with a diagnosis of Alzheimer's disease and a history of exit-seeking behaviors was able to leave the facility's Dementia Care Unit unsupervised and unwitnessed. The resident exited the building, walked approximately one block away, fell in the street, sustained a skin tear over the left temporal region and abrasions on both hands, wrists, and elbows, and then entered an unlocked private vehicle. The resident was found by an off-duty police officer, who noted confusion and inability to provide his address or explain his whereabouts. The resident was subsequently transported to the emergency room for evaluation and treatment of his injuries. The resident's care plan and elopement evaluation had previously identified him as being at risk for elopement, with interventions such as redirection, notification of staff, diversional activities, and 30-minute checks. Despite these interventions, staff were unable to effectively supervise the resident on the day of the incident. Staff interviews and documentation revealed that the resident had been displaying increased exit-seeking and challenging behaviors throughout the day, including attempts to open doors, requests for keys, and verbal aggression. Staff attempted various redirection techniques, but these were unsuccessful. At the time of the elopement, staff were occupied with other residents, and the resident was able to access an unlocked office, open a window, and push out the screen to exit the building without triggering door alarms. Further investigation found that the facility had several environmental and procedural lapses that contributed to the incident. The office door providing access to the window was left unlocked, and the window was unsecured. Additionally, the north exit door's alarm system was not functioning properly, allowing doors to be opened without alerting staff. Maintenance logs showed that door alarms were not being checked daily as required by facility policy, and staff were unaware of this requirement. Staffing levels were also cited as a concern, with staff reporting that increased supervision was not possible due to the number of residents and the level of care required on the unit.
Removal Plan
- R1 was placed on 30-minute checks.
- R1's Care Plan was updated to reflect elopement interventions.
- V9 ensured the office door from which R1 was believed to have accessed a window to elope was locked.
- V5 installed a self-locking doorknob, replaced the window screen and secured the window.
- All residents identified at risk for elopement care plans were updated with interventions, as well as the facility's Elopement Binder by V9.
- V5 installed a self-locking doorknob on the north hall shower room, and secured the window so as not to allow opening.
- V5 and V13, Corporate Regional Director, confirmed the north exit door did not automatically open with 15 seconds of pressure.
- V9 completed Elopement Assessments on all residents of the Dementia Care Unit.
- V14, Minimum Data Set Coordinator, completed a Care Plan audit on all residents of the Dementia Care Unit to ensure Care Plans addressed elopement risk.
- V13 reviewed the Resident Supervision Policy with no changes made.
- V2 and V15, LPN/Assistant DON, completed staff education on resident supervision with all staff.
- V13 completed education for V5 regarding window and door security.
- V5 will complete window and door audits daily for one week, twice weekly for two weeks.
- V2 will complete a Facility Activity Audit to identify exit seeking behavior of residents daily for one week, twice weekly for two weeks, and weekly for 4 weeks.
- V9 will complete an audit of the Elopement Binder to ensure it is up to date according to Elopement Assessments daily for one week, twice weekly for two weeks, and weekly for four weeks.