F0689

J

Resident Elopement Due to Inadequate Door Monitoring and Risk Assessment

Torrance, California Survey Completed on 11-09-2025

Penalty

No penalty information released

Summary

A deficiency occurred when a resident who required minimal assistance with ambulation using a front wheel walker was able to exit the facility through an unsupervised, non-alarmed front door without staff knowledge. The facility did not have a system in place to monitor the front door after the receptionist left for the day, and the door could be freely opened from the inside, allowing residents to leave undetected. Staff were observed propping the front door open with a box of gloves to facilitate staff entry, leaving the entrance unsupervised and accessible to residents and unauthorized individuals. Multiple staff interviews confirmed that the front door was not consistently monitored, and there was no alarm system to alert staff if someone exited through it.

The resident in question had a medical history including acute myocardial infarction, coronary angioplasty, heart failure, COPD, and psychosis. Despite being assessed as low risk for elopement due to an assumption of non-ambulatory status, therapy records and staff interviews indicated the resident was able to ambulate with minimal assistance using a walker. The resident was last seen in his room in the evening and was later found at a local restaurant approximately one mile away, after which he experienced shortness of breath, was transported to a hospital, and subsequently died from cardiac arrest. The inaccurate assessment of the resident's mobility and elopement risk, as well as the lack of appropriate interventions and monitoring, directly contributed to the resident's ability to leave the facility unnoticed.

Additional observations revealed that staff did not respond promptly to exit door alarms, with alarms sounding for several minutes without investigation. Staff interviews indicated confusion about responsibilities for responding to alarms and a lack of clear procedures for monitoring exit doors, especially during times when the front lobby was unsupervised. The facility's policy required identification and care planning for residents at risk of elopement, but this was not followed in the case of the resident who eloped. The combination of inadequate assessment, lack of monitoring systems, and failure to respond to alarms resulted in a serious lapse in resident safety.

Removal Plan

• The Elopement Evaluation for active residents was completed by the Director of Staff Development (DSD), Infection Prevention Nurse (IPN) and Case Manager (CM). Residents identified to be at risk for elopement. The Elopement Evaluation will be completed upon admission, readmission, quarterly, annually, and as needed by the Minimum Data Set Nurse (MDSN)/ Designee. Upon completion of elopement evaluation by the licensed nurse, the Director of Nursing (DON)/Designee will review for accuracy. Resident centered care plans with emphasis on elopement interventions will be reviewed, updated, and completed to ensure resident safety upon completion of the Elopement Evaluation. After completion of Elopement Evaluation, the Licensed Nurse will initiate interventions/measures such as one to one (1:1) monitoring, sitter, hourly rounding, place resident in a supervised area when in wheelchair, re-route resident when attempting to seek exit, engage resident in activities of choice.
• The care plan for residents identified to be at risk for elopement was reviewed and updated by DON/Designee. The care plan interventions included measures such as: hourly rounding, placed in supervised area, redirection / rerouting. Residents placed on 1:1 monitoring for 24 hours and will be evaluated by the Interdisciplinary Team (IDT) for continuation or discontinuation. Residents in the same room were placed on a sitter for 24 hours and will be evaluated by the IDT for continuation/discontinuation.
• The IDT initiated a care plan meeting for residents identified to be at risk for elopement with a follow up call to the resident's representative by the IP Nurse.
• The Maintenance Director checked facility egress doors and tested all audible door alarms for functionality. There were no negative findings identified in all exit doors. Egress tests and checks will be maintained daily for four weeks then weekly thereafter by the Maintenance Director. Exit Door Audit logs will be completed by Maintenance Director /Designee daily. The Administrator will perform validation rounds on door and alarm testing once a week. If the alarm is not working, maintenance will be notified via TELS, Maintenance department will fix and if more time needed, a staff member will be assigned to monitor door until it is fully operational. If a resident is observed attempting to leave using the egress door, staff will redirect and prevent the resident from leaving and notify the Licensed Nurses for further action / interventions.
• The DON/Designee initiated skills competency to licensed nurses on resident admission and elopement with emphasis on identifying risks, prevention, interventions, and door security procedures to ensure all exit doors are attended and checked for resident safety. The DSD/Designee initiated in-service training to Certified Nursing Assistant (CNA) on elopement policy with emphasis on prevention, interventions, monitoring of all exit doors and alarm system, identification of elopement risk residents, location of elopement binders and pink wristbands as elopement identifier. Staff training provided by the DSD/Designee on monitoring all exit doors and ensuring all exit doors are secured and alarm in place. Staff training with emphasis on ensuring all exit doors are secured and an alarm in place: a. The front door will be unlatched, and the alarm will be turned off by the receptionist on duty to allow entrance and exit of facility staff and visitors. b. The front door activity will be monitored by the receptionist on duty. c. The receptionist, before leaving for the day, will inform the licensed nurse to ensure continuity of monitoring of the front door. The licensed nurse will ensure the front door is fully latched, and the alarm is turned on. d. An assigned staff from 3p.m. to 11 p.m., and 11-7 p.m., will monitor the exit doors. The DSD/Designee is responsible for preparing the daily assignment for checking the exit doors that are latched and alarms on. An exit door and alarm monitoring log will be completed by the assigned Nursing staff to document the checking of all doors and alarms as assigned hourly. e. Any licensed nurse on leave will receive training on their next scheduled workday prior to their shift.
• The DON/Regional Clinical Resource initiated an in-service to the nursing staff regarding the updated resident elopement binder which is located at each nurse's station and reception area that has the following information: a. List of residents that are elopement risk b. Guide for staff on steps to take in case of elopement: Refer to Elopement Policy included in the binder as well as the list of the local police and fire department, and nearby acute hospitals in the area. c. Each resident packet includes demographic information which includes a copy of the resident's latest photograph, face sheet, elopement risk identification, most recent elopement evaluation, and updated elopement care plan.
• The DON/Designee is responsible for updating the content of the Elopement Binder for any newly identified and or changes in resident elopement evaluation and plan of care. Any new information, updates or changes with the list of residents in the Elopement Binder will be communicated by the DON / Designee with the nursing staff during the shift huddle and Point Click Care Communication Home Page. A pink wristband will be applied to a resident by the DON/Designee and to be worn by a resident determined to be an elopement risk based on evaluation. The pink wristband will include the resident name, date of birth identification, facility address, and telephone number. The department managers will check out the resident pink wristband during the daily Patient Centered Rounds to ensure wristbands are in place and worn per plan of care. Registered Nurse (RN) Supervisors responsible for checking the wristbands on weekends. If pink wristbands are not in place, Department Managers will notify the DON/Designee for replacement. On weekends, the Registered Nurse Supervisor (RNS) will replace the pink wristbands which are available at Station 1.
• The Medical Director was informed by DON regarding the incident. No new orders were given.
• The Elopement Binder was reviewed and updated by the DSD/Designee and placed at each nursing station and the reception area.
• The DSD/Designee placed pink wristbands to residents as an elopement identifier.
• The Maintenance Director initiated daily checks on all exit doors to ensure they were properly latched and alarms functioning.
• Nursing staff from 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m., shifts. The DSD/ Designee is responsible for preparing the daily assignment for checking the egress doors and alarms of exit doors and if properly latched with alarms on. An exit door and alarm monitoring log will be completed by the assigned Nursing staff to document the checking of exit doors as assigned hourly.
• The facility installed an alarm on the front lobby door, with a key in a red key holder located inside the reception area.
• The receptionist hours were increased, with the expectation to monitor the front door lobby for residents leaving or attempting to leave unattended. In case of receptionist is not available during break, another staff will cover to ensure continuity of monitoring is in place.
• The Administrator and Regional Nurse Consultant provided 1:1 in service training to RNS 1 and reviewed elopement policy with emphasis on accurate assessment of a resident determined to be at risk for elopement which includes reviewing records from GACH, initiating care plan interventions to maintain resident safety and facility's elopement policy and procedures. Inservice and education with the licensed nurses was also initiated regarding accurate assessment and elopement policy with emphasis on accurate assessment of a resident determined to be at risk for elopement which includes reviewing records from GACH, initiating care plan interventions to maintain resident safety and facility's elopement policy and procedures.
• The Administrator will report findings to the Quality Assurance and Performance Improvement (QAPI) Committee on the outcome of resident elopement evaluation and system implementation status update for review and further action as needed.
• The facility's policies and procedures regarding elopement and wandering residents were reviewed by IDT. Interventions such as 1:1 monitoring, providing a sitter, and hourly safety checks as needed.
• The facility revised its facility's new admission decision tree to include questions about history and frequency of wandering and elopement prior to resident admission to the facility. The admissions coordinator will inquire about additional information regarding elopement, history of wandering- and will be discussed with the team: Administrator, DON, and Social Service Director (SSD). DON will audit new admissions daily.
• DSD/Designee will train new hires in wandering, elopement, and resident safety procedures during orientation.
• All findings will be discussed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting for a minimum of three months or until the pattern of compliance is maintained.