Failure to Prevent Elopement from Secured Memory Unit
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement and diagnoses including paranoid schizophrenia, cognitive impairment, and wandering behaviors exited a secured memory care unit without staff intervention. The resident was identified as an elopement risk, with documentation in the elopement binder and care plan noting previous incidents of leaving facilities and attempts to hide or leave unnoticed. On the evening of the incident, the resident exited through a locked door that required a code, which triggered an alarm. However, staff did not immediately recognize the alarm as indicating an exit from the men's unit, partly due to previous issues with a different door alarm and staffing shortages at the time. Only one CNA was present on the hall, as the other was on break, and the nurse was occupied with medication administration on another hall. The alarm was initially misattributed to a sticking door on the women's side, leading to a delay in response. Staff did not immediately check the source of the alarm, and a head count was not initiated until after the alarm had sounded and the resident had already left the building. The resident was unaccounted for during the head count, and a search was initiated. The resident was missing for over two hours, during which time local authorities, canine units, and a helicopter with infrared technology were involved in the search. The resident was eventually found in a residential area, having traversed steep and overgrown terrain in the dark. Interviews with staff revealed that the split staffing and miscommunication about the alarm contributed to the delay in identifying and responding to the elopement. The CNA present on the men's hall had hearing issues and did not immediately investigate the alarm, assuming it was related to the previously malfunctioning door. The nurse and other staff were not immediately aware that the resident had exited, and the search only began after the head count confirmed the resident was missing. The resident was ultimately found unharmed, but the lack of adequate supervision and delayed response allowed the resident to leave the facility unnoticed and unsupervised for an extended period.
Removal Plan
- R2 was moved to a room closer to the nurse's station.
- R2 was placed on 1:1 supervision with re-evaluation.
- R2's elopement risk was re-evaluated.
- A psych medication review was requested for R2.
- Administrator and Director of Nursing were in-serviced by the VP of Clinical Services.
- Administrator in-serviced the Intradisciplinary Team (IDT).
- Current staff were in-serviced on elopement policy and procedure.
- All residents in the facility had an elopement risk assessment completed.
- Elopement Binder was updated based on those risk assessments.
- Review of policy and procedure was completed to reflect current practice.
- All staff were in-serviced on elopement and procedures on steps to take if a resident is at risk.
- All facility staff were in-serviced for elopement and staffing.
- A QA tool was implemented along with audits of the 24-hour report for wandering/elopement risks.
- Audit for elopement risk assessments completed within admission.
- Audits to continue to ensure that elopement risk is documented.
- Root Cause Analysis completed for elopement.