Failure to Ensure Elopement Prevention Device Placement and Monitoring
Penalty
Summary
A deficiency occurred when a cognitively impaired resident, identified as being at risk for wandering and elopement, was not provided with the required elopement prevention device (TekTone bracelet) as per facility policy and physician orders. The resident had a history of dementia, cognitive decline, and other medical conditions, and was care planned for frequent visual checks and interventions to prevent elopement. The facility's policy required that the TekTone device be checked every shift, and the physician's order specified the same; however, the order was incorrectly transcribed to require checks only once weekly, and documentation showed the device was last checked three days prior to the incident. On the night of the incident, the resident was not in their room during medication administration, and staff had not seen the resident for over an hour before the resident was found outside the facility. The resident was discovered in the rear parking lot without the TekTone device, having sustained a large hematoma and a left hip fracture. Staff interviews confirmed that the resident did not have the device on at the time of the incident, and that checks for the device were not performed as required by policy or physician order. Further review revealed that the resident had previously removed the TekTone bracelet, and there was no evidence in the records that the device was consistently in place or checked as required. The facility was unable to provide documentation that the required checks were performed, and the resident's elopement was facilitated by the absence of the device, which would have triggered door locks to prevent exit. The failure to follow policy and physician orders directly led to the resident's successful elopement and subsequent injury.