Resident Elopement Due to Unsecured Exit and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a traumatic brain injury and a known history of agitation and elopement risk was able to leave the facility unsupervised through unsecured doors. The resident was last seen in his room and, after a door alarm was heard, staff discovered that the resident was missing. The facility's elopement protocol was activated, and the resident was found by law enforcement approximately 0.2 miles from the facility after being unattended for about 45 minutes. The doors used for the elopement were not equipped with a wander guard alarm system, and the area was not occupied by staff or residents at the time. Interviews and record reviews revealed that the exit doors on certain units, including the one used during the elopement, had not been secured with a wander guard alarm system for at least four years. Staff believed that the emergency exit door alarms were sufficient, but these alarms only sounded when the door was opened and did not provide the same level of alert as the wander guard system. Additionally, the resident's care plan had previously included 1:1 monitoring and a wander guard device, but the monitoring was discontinued following an IDT review, and there was uncertainty among staff about the evaluation process and documentation for this decision. Further review showed that multiple other residents were assessed as being at risk for elopement and were supposed to have wander guard devices in place, with staff required to check these devices every shift. However, interviews indicated that these checks were not consistently performed, and some staff were unclear about who was responsible for ensuring the devices and door systems were functioning. The facility's own elopement policy required regular checks of both door keypads and monitoring devices, as well as immediate staff response to alarms, but these procedures were not reliably followed.