Failure to Prevent Elopement Due to Inadequate Supervision and Malfunctioning Alarms
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not ensuring staff maintained a secure environment and implemented measures to prevent elopement. A male resident with severe cognitive impairment, Alzheimer's disease, dementia, and a history of wandering was identified as an elopement risk and had interventions in place, including an electronic wander alert bracelet and hourly rounding. Despite these interventions, the resident was able to exit the facility unsupervised during the early morning hours, and his absence went unnoticed by staff for over two hours until he was found by staff arriving for the day shift. Interviews with staff revealed that there were lapses in supervision and communication. The CNAs and the LPN on duty were not fully aware of the resident's elopement risk or the need for specific supervision. The nurse assigned to the unit was an agency nurse unfamiliar with the residents and was not informed about the resident's exit-seeking behavior. Staff did not hear any alarms during the incident, and it was later discovered that the electronic wander alert system and door alarms were malfunctioning. Maintenance records confirmed that the alarm system at the relevant exit door had been out of order prior to the incident, and a vendor had been called for repairs, but no interim measures were put in place to monitor the door until after the elopement occurred. Documentation also showed that staff failed to complete required hourly rounding as indicated in the resident's care plan, with no evidence that rounds were conducted as instructed. The facility's own investigation and root cause analysis confirmed that inadequate supervision and failure to secure the fire exit door after the resident attempted to exit earlier in the shift contributed to the elopement. The lack of functioning alarms and insufficient staff awareness and supervision directly led to the resident's unsupervised exit from the facility.
Removal Plan
- Resident #1 was assessed on return to the facility and had no injuries. A head count was conducted to verify the safety of all residents. Resident #1 was placed on one-to-one supervision.
- Patient Health Questionnaire (PHQ) evaluations were completed by the Licensed Clinical Social Worker for resident #1 for three consecutive days. Resident #1 did not exhibit any signs or symptoms of mental anguish or distress.
- Employees were assigned to sit near the exit door on every shift until all the alarm settings and door functions were completed. The person designated to monitor the door had full view of the other two doors located on the secured unit.
- Hourly unit monitoring was initiated and facility management increased their presence on the floor.
- The facility conducted an elopement drill and continued daily drills on every shift. Elopement Drills were completed weekly on each shift.
- The maintenance team was educated by the Administrator to ensure doors functioned appropriately and if identified as dysfunctional to immediately initiate door monitoring process, notify the Nursing Home Administrator (NHA), DON and Operations Review Specialist and begin repairs as appropriate.
- Staff education began which included abuse, neglect, responding to alarms, resident monitoring/supervision and accountability. Education was provided to staff on a rolling basis until 95% of staff were educated. Remaining staff will be educated upon return from leave and are scheduled to work.
- All audits for corrective measures were reviewed in the Ad HOC QAPI meetings.
- All audits for corrective measures were reviewed in monthly QAPI meeting and will be reviewed monthly for a minimum of three months or more until substantial compliance is achieved.
- Staff interviews were conducted with 14 staff members representing all shifts to ensure knowledge of elopement policy and procedures, appropriate response to alarms and supervision of all residents to include those at risk for elopement, abuse and neglect.
- The resident sample was expanded during the survey to include four additional residents who were at risk for elopement. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations, care plans and physician orders for residents #8 through #11.