Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with dementia, schizophrenia, and anxiety disorder, who was identified as being at risk for elopement, exited the facility unsupervised. The resident had a history of exit-seeking behavior and was on an hourly visual monitoring protocol, as well as equipped with a wander guard device. Despite these interventions, surveillance footage showed the resident leaving the unit without staff noticing, and subsequently exiting through the East COVID entrance door, which triggered an alarm. Staff interviews revealed that the assigned CNA had left for a break after notifying other staff of their absence, and the RN on duty did not observe any immediate exit-seeking behaviors from the resident. The wander guard was reportedly functional, but staff did not hear any alarms from the elevator or exit doors at the time of the incident. The alarm at the East lobby entrance was deactivated by a security officer without a thorough investigation or notification to the Director of Security, contrary to facility policy. The resident's absence was not confirmed until a headcount was conducted, and the elopement was only discovered after a significant delay. The investigation documented that multiple staff members, including security and nursing, did not detect the resident's departure in real time, and the required monitoring and response protocols were not effectively implemented. The resident was eventually located by police and transported to the emergency room without injury. The failure to provide adequate supervision and to properly respond to the triggered alarm resulted in the resident's unauthorized exit from the facility.