Failure to Prevent Elopement and Ensure Door Security for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including Alzheimer's disease, dementia, anxiety, unsteadiness, and muscle weakness, was identified as high risk for elopement and falls. The resident's care plan and assessments documented severe cognitive impairment, wandering behaviors, poor safety awareness, and a need for close monitoring and staff assistance with mobility and activities of daily living. Despite these risks, the resident was able to exit the facility through an unlocked and unalarmed door in the 200 hall, which failed to secure properly due to the alarm being unhooked, reportedly by contractors. The mag-lock on the door did not engage, allowing the resident to leave the premises unsupervised. After exiting, the resident traversed a hazardous environment, including cracked sidewalks, uneven grassy areas, a parking lot with large potholes, and several curbs. The resident ultimately fell between two apartment buildings behind the facility. The incident was discovered when a community member called 911, and facility staff identified the resident on an ambulance stretcher. The resident sustained facial abrasions and a urinary tract infection, requiring hospital evaluation and treatment. Staff statements confirmed that the resident was last seen at the nurse's station and that there was a delay in realizing the resident was missing, leading to a search and eventual discovery of the incident by observing the ambulance outside. Facility records and staff interviews revealed that the door alarm was not functioning at the time of the incident, and the required supervision and monitoring for a high-risk resident were not adequately provided. The facility's elopement policy required individualized care planning and routine security monitoring, but these measures were not effectively implemented, resulting in the resident's unsupervised exit and subsequent injury.
Removal Plan
- 1200-pound mag-locks were installed on all doors.
- The door at the end of 200 hall was secured, and the mag-lock was functioning.
- The alarm was rewired and in working order.
- All staff were re-educated on the facility's elopement policy.
- Stop signs were placed on each exit door, and the signs also requested contractors to alert staff before using the exit doors so staff could stay at the exit doors until the contractors were done.
- The facility's Elopement Book was reviewed for accuracy.
- R1 was put on one-to-one.
- The findings of the incident were taken to an emergency QAPI.