Failure to Prevent Elopement and Maintain Functional Safety Alarms
Penalty
Summary
The facility failed to provide adequate supervision and maintain functional safety systems to prevent elopement and accidents for residents with severe cognitive impairment and a history of wandering. One resident with dementia and a BIMS score indicating severe cognitive impairment was left unsupervised, allowing the resident to pass through alarmed doors and access a stairwell, resulting in a fall down two flights of stairs. The alarms on the doors and the resident's Wanderguard device were activated, but staff did not respond appropriately to the alarms, and the resident was found on the stair landing with multiple bruises. Other residents at risk for elopement were also not adequately protected. One resident with a history of wandering and a BIMS score indicating severe cognitive impairment had a Wanderguard bracelet in place, but this intervention was not documented in the care plan. Another resident with severe cognitive impairment and a history of wandering had a Wanderguard bracelet, but there was no documentation of wandering behaviors in the progress notes, despite care plan interventions requiring monitoring and documentation. Additionally, multiple Wanderguard alarm units on the first floor were found to be nonfunctional for extended periods, with staff and maintenance aware of the issue. Doorbell alarms were installed as a substitute, but staff did not respond when these alarms sounded during observations. The lack of functioning elopement prevention systems and inadequate staff response to alarms contributed to the failure to ensure a safe environment and adequate supervision for residents at risk of elopement.