Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition, dementia, and a history of wandering and elopement risk exited the facility without staff knowledge or intervention. The resident was equipped with a WanderGuard device, and his care plan included supervision, frequent checks, and specific interventions to address his elopement risk. Despite these measures, the resident was able to trigger multiple door alarms and exit the building, remaining missing for approximately five hours before being located by police several miles away from the facility after dark. The sequence of events leading to the deficiency involved several lapses in staff response and supervision. When the resident's WanderGuard triggered alarms at multiple exit points, the receptionist received the alerts and attempted to notify the charge nurse. However, the response was delayed, and staff did not immediately conduct a thorough search of the property or check outside the building. The receptionist missed a critical alarm while away from her desk, and staff searches were limited to certain areas inside the building. Camera footage later confirmed the resident had exited the building, but this was not reviewed in time to prevent his departure. Interviews with staff revealed that expected protocols, such as immediate response to alarms and comprehensive searches, were not fully followed. Staff acknowledged that they should have checked outside as soon as the alarms were triggered and that more proactive measures could have prevented the resident from leaving the premises. The facility's elopement prevention policy required immediate and thorough searches, but these actions were not effectively implemented during the incident, resulting in the resident's prolonged absence and exposure to potential harm.
Removal Plan
- Facility began immediate investigation.
- Upon R1's return to facility a complete head to toe assessment was completed and every 30-minute safety checks were implemented due to risk of reoccurrence.
- All staff mandatory meetings have been held. Education included: elopement, missing resident, facility policies and procedures, and this specific incident and interventions had been discussed.
- Frequent checks will be completed if statements are made about leaving.
- Elopement checks will be completed if R1 makes statements about leaving.
- Elopement drills will be conducted.
- Wander guard system was checked and in working order.
- Policies were reviewed, elopement and missing resident. no changes needed.
- Other high elopement resident charts and care plans were reviewed, and triggers and interventions were added as needed.
- Pictures of high-risk elopement residents had been dispersed to all departments to review routinely. Pictures updated with any changes.