Failure to Prevent Elopement Due to Inadequate Supervision and Alarm Issues
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with severe cognitive impairment from eloping. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and a cognitive communication deficit, was identified as an elopement risk and had a care plan in place that included 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. Staff assigned to monitor the resident did not notice his absence until he was found outside the facility by another staff member arriving for work. Interviews with staff revealed that there were two CNAs and one nurse on duty at the time of the incident. The CNAs reported that they had asked the nurse to watch the residents while they assisted other residents, but the nurse left to administer medications, leaving the residents unsupervised. None of the staff on duty heard any door or wander alert alarms during the shift, and the resident's absence went unnoticed for an extended period. The resident was eventually found in the front vestibule of the facility by a staff member arriving for work, and staff on the unit were unaware he was missing until he was returned. A review of the resident's likely elopement route showed that he exited through a fire exit door, traversed various outdoor areas including a parking lot, a two-lane road, and landscaped beds, before entering the front vestibule. Along the way, he passed potential hazards such as an electric generator, commercial dumpsters, and a retention pond with an unlocked gate. The facility's elopement policy stated that alarms are meant to assist but do not replace necessary supervision, and the root cause analysis by the facility's QAPI Committee determined that staff failed to provide appropriate supervision, with alarm and door function issues also contributing to the incident.
Removal Plan
- Resident #1 returned to the secured unit with facility staff. He was assessed on return to the facility and had no injuries. A head count was conducted to verify the safety of all residents. The required notifications were made to the physician and family. 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.
- Resident #1 was re-evaluated for elopement risk and the elopement risk care plan was updated.
- Employees were assigned to sit near the exit door on every shift until all the alarm settings and door functions were completed.
- A vendor was called and came in to assess the door and submit work order.
- The red screamer alarm annunciator was changed to alarm continuously until silenced by use of a key.
- All resident wander alert bracelets were checked for all residents identified as at risk for elopement and verified as functional.
- All residents were reassessed for elopement risk and re-evaluated.
- All elopement binders in place were reviewed by Registered Nurse (RN) Supervisor and found to be accurate with 23 residents identified as at risk for elopement. Elopement binders were updated with every new admission, new elopement assessment, discharge and as needed.
- All locations of the wander alert system were evaluated and found to be in working order.
- Maintenance Department staff audited wander alert system for functionality at all locations and conducted daily audits for one month and then weekly thereafter.
- Maintenance checked all doors to ensure they locked and latched; and audited the doors for functionality daily for week then weekly for three months then monthly thereafter.
- Care plans were reviewed for all residents identified to be at risk for elopement.
- Wander alert bracelets are checked daily for functioning and noted on the Treatment Administration Record.
- 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 Administrator, DON and Operations Review Specialist and begin repairs as appropriate.
- Staff education began which included abuse, neglect, elopement policy and responding to alarms, and door alarm function. Remaining staff will be educated upon return from leave and are scheduled to work.
- The magnetic lock on the fire exit door was repaired.
- The elopement/wander alert device was upgraded on the identified fire exit door.
- All audits for corrective measures were reviewed in the Ad HOC QAPI meetings.
- All audits for corrective measures were reviewed in monthly QAPI and will be reviewed monthly for a minimum of three months or more until substantial compliance is achieved.
- Interviews were conducted with staff members representing all shifts. Staff interviews revealed they were knowledgeable of the elopement policy and procedures, appropriate response to alarms and supervision of all residents to include those at risk for elopement, abuse and neglect.