Failure to Prevent Elopement Due to Inadequate Supervision and Unattended Front Desk
Penalty
Summary
A resident with severe cognitive impairment, diagnosed with Alzheimer's Disease, dementia, anxiety, and major depression, and under legal guardianship, was assessed and care planned as being at risk for elopement. The resident's care plan included monitoring for exit-seeking behaviors, such as following visitors and pacing near exit doors and elevators. Despite these interventions, the resident was able to leave a secured unit on the second floor by following a visitor onto an elevator that required a passcode, and subsequently exited the building through the front door by following another visitor. At the time of the incident, the front desk, which controlled the security release for the front doors, was left unattended by the receptionist, who stepped away for 5-10 minutes without arranging for coverage. This allowed the resident to exit the building unsupervised. The resident was later found outside near the back of the facility by a CNA, who was returning from a break. The resident stated they were looking for their car and did not recall how they got outside. The incident was not immediately known to staff, and the resident was outside for approximately 10 minutes before being escorted back inside. Interviews with staff and review of facility policies revealed that it was against facility policy to leave the front desk unattended, and that receptionists were expected to have coverage when stepping away. The facility's elopement policy defined elopement as a resident leaving a safe area without authorization or necessary supervision. The failure to provide adequate supervision and monitoring, as well as leaving the front desk unattended, directly led to the resident's unsupervised exit from the building.
Removal Plan
- A schedule has been established to monitor the involved R600 every 15 minutes.
- R600's elopement care plan was reviewed and updated to reflect activities of interest including model care that he can design, music, bingo, purposeful wandering.
- Notification sent to families/representatives on not letting self out of the building, which is a breach of our security systems.
- Residents identified at risk for exit seeking were assessed to reduce opportunity to exit facility; their care plans were reviewed, photos updated if necessary, Medical Director and responsible parties notified to be aware of surroundings when on elevator.
- Committee will continue to monitor and perform analysis for any potential root cause to variation in updated systematic process.
- Signage has been placed by and in the elevator to remind visitors to be aware of anyone on the elevator without a badge/nametag may be an indication of an unaccompanied resident and to notify a staff member immediately.
- All current residents' elopement risk evaluations were reviewed and updated with care plans reviewed and updated as needed.
- Front door push button relocated and a protective cover placed over it so visitors cannot reach over the counter and push the button.
- Staff educated on elopement, front desk to be attended during business hours.
- Education on proper visitor sign in/out process.
- Elopement policies were reviewed.
- Elopement risk list updated.
- Elopement investigation procedure and documentation process were reviewed.
- Elopement drill was completed multiple shifts.
- Elopement audits completed.