Failure to Prevent Resident Elopement Due to Inadequate Supervision and Environmental Hazards
Penalty
Summary
A deficiency occurred when a resident with a history of mild cognitive impairment and alcohol abuse eloped from the facility. The resident had previously been assessed as low risk for elopement upon admission, but subsequent assessments identified her as high risk, and interventions such as a wander guard and daily checks were implemented. Despite these measures, the resident was able to leave her room, pass through two sets of double doors, enter a staff break room, and exit through a storage room door that led to a loading dock. The door she used to exit had a broken lock and was not equipped with an alarm for the wander guard, allowing her to access the dock undetected. Staff interviews and video footage revealed that a housekeeper present in the break room did not notice the resident entering or exiting, as she was distracted by her phone. The resident was found outside on the loading dock by another staff member, who alerted maintenance. The maintenance team and a CNA assisted the resident back inside, and she was assessed for injuries, with none found. The incident was not immediately recognized as an elopement by facility leadership, and there was a lack of communication regarding the broken door lock prior to the event. Maintenance staff reported that no work orders had been submitted for the faulty lock, and the door was not discussed in morning meetings following the incident. The facility's policies required that residents at risk for elopement receive adequate supervision and that the environment remain as free from accident hazards as possible. However, the resident was able to leave the building through an unsecured and unmonitored exit, and staff failed to provide the necessary supervision to prevent the elopement. The incident was not promptly reported or fully investigated at the time, and the care plan was not updated with additional interventions after the resident's risk status changed. These failures resulted in the resident being exposed to significant risk while unsupervised outside the facility.
Removal Plan
- The Unit Manager completed a head-to-toe skin assessment and pain evaluation of R529 with no injuries or pain noted.
- The wander guard to her left ankle was noted to be in place.
- R529's Physician and family/responsible party were notified of the event.
- The Maintenance Director inspected the storage door and found the lock to be broken.
- The door was repaired by placing a keypad lock on it.