Failure to Prevent Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with a history of cognitive impairment, mild dementia, and alcohol use disorder exited the facility without staff knowledge or appropriate supervision. The resident, who was assessed as being at risk for elopement and had an electronic wander bracelet in place, was able to leave the facility by following another resident out the door, which was remotely opened by staff. The door alarm was triggered but subsequently disabled by another resident who knew the code, and no staff were present in the reception area to respond to the alarm or monitor the exit. The resident walked approximately 0.2 miles to a nearby hospital and was returned to the facility by law enforcement several hours later. Prior to the incident, the resident had demonstrated behaviors such as wandering, confusion, and expressing a desire to leave the facility. Documentation showed that the resident had a BIMS score indicating moderate cognitive impairment and was independently mobile with a walker. Staff and family interviews confirmed the resident's history of confusion, exit-seeking behavior, and lack of safety awareness. On the day of the incident, staff failed to provide adequate supervision, did not respond to the exit alarm, and allowed a situation where residents could access and disable the alarm system due to unsecured door codes. The facility's records revealed that the elopement was not documented in the abuse/neglect log or the incident and accident report. Staff interviews indicated a lack of awareness and response to the alarm, and video evidence confirmed that no staff were present in the area at the time of the exit. The resident's care plan included interventions for elopement risk, but these were not effectively implemented, resulting in the resident leaving the facility unsupervised and unnoticed for an extended period.
Removal Plan
- Resident #1 was put on enhanced supervision and then moved to the secure unit.
- An audit was completed by the DON and the facility's clinical administration team for current residents to ensure accuracy of assessment for cognition and mobility.
- Identified variances were corrected regarding LOA status.
- Staff were educated on the policy and procedures related to resident supervision, following procedures for residents leaving the facility for leave of absence, as well as the facility unauthorized exit protocols.
- Staff were educated by the DON and the facility clinical administration team on the door code process and the process to report unauthorized knowledge of the facility door codes.
- The remote door releases were deactivated.
- Code Silver drills were completed every shift.
- Random audits were completed regarding unauthorized exit, resident LOA status, and resident elopement risk.
- Ad hoc QA meeting was conducted to review the removal plan, which included the medical director.