Failure to Prevent Elopement Due to Inadequate Supervision and Door Alarm Systems
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including dementia, cerebrovascular disease, diabetes, and osteoporosis, was able to leave the facility unsupervised. The resident had a documented history of wandering and previous elopement attempts, and was identified as being at high risk for elopement based on assessment tools and care plans. Despite these known risks, the resident was last seen in the facility approximately 30 minutes before being found by law enforcement at a grocery store half a mile away. The facility's monitoring systems and supervision protocols were inadequate to prevent the elopement. Staff interviews revealed that the facility previously used a monitoring system with bracelets for at-risk residents, but this system had been removed and not replaced. The front entrance door, through which the resident exited, only had an active alarm during nighttime hours and was not monitored by an alarm during the day. Additionally, the back door of the dining room was found to be unlocked and without an alarm unless specifically set up, and staff were not consistently monitoring these exits. Staff also reported that only one resident was assigned 1:1 supervision, despite multiple residents being at risk for elopement. Facility policy required adequate supervision and the use of door alarms for residents at risk of wandering or elopement, but these measures were not effectively implemented. Staff interviews confirmed that the lack of a functioning monitoring system and insufficient supervision allowed the resident to leave the facility undetected. The deficiency was further compounded by a lack of awareness among leadership regarding the status of door alarms and the absence of consistent monitoring protocols for all at-risk residents.