Failure to Prevent Elopement Due to Inadequate Supervision and Unsecured Exit Codes
Penalty
Summary
The facility failed to adequately monitor and supervise a severely cognitively impaired resident, resulting in the resident exiting the facility without staff knowledge. The resident, who had a history of traumatic brain injury and a BIMS score indicating severe cognitive impairment, was able to access and use an exit door code that had been provided to certain residents by staff. This allowed the resident to leave the facility unsupervised and travel approximately 250 feet away, where they were found by a community member. At the time of the incident, the resident was observed in the lobby near the front door and subsequently exited the building using the code. Staff were unaware of the resident's departure until notified by an individual who saw the resident outside her home. The resident was outside for approximately 30 minutes in hot weather conditions before being returned to the facility by staff. Interviews with staff indicated that residents not considered at risk for elopement had access to the exit code, and the resident in question was not previously identified as having exit-seeking behaviors. The facility's elopement policy required identification and monitoring of residents at risk for unsafe wandering, but the failure to secure exit codes and supervise the resident led to the elopement event. Documentation and interviews confirmed that the resident was not injured during the incident, but the lack of adequate supervision and unsecured exit codes constituted non-compliance with requirements to prevent accidents and ensure resident safety.
Removal Plan
- Resident #46 was placed on the secured unit following their return to the facility.
- Elopement assessments were completed for all residents including Resident #46. The care plan for each resident identified at high risk of elopement was reviewed and updated as necessary.
- The administrator/designee initiated an in-service for staff on elopement and/or wandering. All staff have/will be in-serviced prior to working their next shift. The in-service was completed.
- Exit door codes were changed, and continue to be changed monthly or as needed.
- Staff was ordered to monitor behaviors and triggers for Resident #46.
- Window stoppers were placed on the windows of the secured unit to prevent residents from opening the windows and removing screens to leave the facility.