Elopement of Cognitively Impaired Resident Through Unsecured Bathroom Window
Penalty
Summary
A cognitively impaired resident with a history of dementia, agitation, and behavioral disturbances, who was assessed as an elopement risk, was able to exit a secured memory care unit unsupervised through a bathroom window. The resident had previously demonstrated wandering behaviors, including attempts to leave the facility and a history of elopement or attempted elopement at home. The care plan identified the resident as an elopement risk and included interventions such as structured activities, diversions, and supervision, but did not address the risk posed by windows in the resident's room and bathroom. On the night of the incident, staff last observed the resident in his room at 2:15 a.m. During a subsequent check at approximately 4:00-4:15 a.m., the resident was found missing, with a chair placed under the bathroom window, which was open. The window's safety mechanisms, two plastic pieces intended to prevent it from opening fully, had been broken off. The resident exited through the window without staff knowledge, crossed a busy intersection, and was later found at a local gas station by emergency services. The resident reported falling while climbing out of the window and was observed with an abrasion on his arm. Family members had previously expressed concerns to staff about the risk of the resident attempting to escape through windows, noting that the bathroom window had been seen open and that the resident had a history of such behavior. However, staff and management were either unaware of the windows' ability to open or had not prioritized securing them in the resident's bathroom. The facility's elopement policy referenced door locks and alarms but did not specifically address window hazards, and not all windows had safety blocks installed prior to the incident.
Removal Plan
- Audit of all residents was completed and elopement assessments were updated
- Education was given to all staff on elopement protocol
- Elopement drills were conducted on every shift
- All windows in the facility were audited to ensure safety blocks were in place
- All identified windows missing safety blocks were installed