Failure to Prevent Elopement Due to Disabled Door Alarm and Inadequate Care Planning
Penalty
Summary
A deficiency occurred when a cognitively impaired resident, identified as being at risk for elopement and falls, was able to leave the facility unsupervised in a wheelchair during nighttime hours. The exit door used by the resident was not properly alarmed or monitored, as staff had disabled the door alarm due to multiple visitors and insufficient staff to monitor the front area. The resident exited the facility unnoticed and traveled approximately three-tenths of a mile down a country road, crossing uneven terrain and railroad tracks, before being found by a local citizen who notified facility staff. The resident had a documented history of cognitive decline, major depressive disorder, Parkinson's disease, and other significant medical conditions, including recent episodes of unresponsiveness and ongoing suicidal ideations. The care plan for this resident noted confusion, high fall risk, and a history of turning off safety alarms, but failed to include adequate interventions to address the risk of elopement. Staff interviews revealed that the resident had been exhibiting exit-seeking behaviors and had previously expressed a desire to leave the facility, yet the care plan was not updated in a timely manner to reflect these behaviors or to implement necessary safety measures. At the time of the incident, staffing levels were low, with only one CNA and one nurse present for 37 residents on the unit. Staff did not hear any alarms when the resident exited, and the exit code had been posted on the door for years, making it accessible to residents. There was no physician order permitting the resident to leave the facility unattended, and the facility's policy required staff to know the whereabouts of all residents and to respond promptly to door alarms. The failure to ensure the exit door was alarmed and monitored, combined with the lack of an effective care plan for a resident at risk for elopement, directly led to the resident leaving the facility unsupervised.
Removal Plan
- Placed an alert band on R1 to ensure his safety.
- Completed a new elopement evaluation for R1 and placed R1 on monitoring checks to monitor exit-seeking behavior.
- Completed an audit of all wandering residents by the Social Service Director.
- Initiated training for all staff on identifying exit-seeking behaviors, placing wander alert bands immediately when identified at risk, physician orders, and where to locate the wander guard bands.
- Included training on the location of wander guard exit doors, alarm panels, immediate response to a door alarm or wander guard alarm, and completing safety checks indoors and outdoors.
- Reviewed and trained staff on the Door Alarm and Missing Person and Elopement Policy and Procedures.
- Reviewed the Missing Person and Elopement Policy and Procedures by the Corporate Clinical Director.
- Reviewed and revised Care Plans as necessary by the Social Services Director to update interventions as appropriate.
- Began audits of all exit doors by the Maintenance Director to ensure proper function of all door alarms.
- Started audits of all residents at risk for wandering by the Director of Nursing to ensure Elopement Assessments and Care Plans are up to date with accurate information and interventions.
- Planned to bring the audits to the Quality Assurance meetings to be reviewed by the interdisciplinary team.