Failure to Prevent Elopement and Ensure Resident Safety
Penalty
Summary
A resident with diagnoses of vascular dementia and Alzheimer's dementia, who was identified as being at risk for elopement, exited the facility unsupervised while wearing a wanderguard device. The resident was able to leave through the G-hall exit door without staff knowledge, and the wanderguard alarm did not sound as expected. The resident was later found by a member of the community approximately 0.6 miles from the facility, having sustained multiple injuries including a laceration and hematoma to the forehead, periorbital edema, abrasions to the left knee and shoulder, and skin tears to the left hand. The resident was transported to the hospital for treatment of these injuries. Review of the resident's clinical record showed that the care plan included interventions for elopement risk, such as securing facility exits and using a wanderguard device, with orders to check the device for placement and function. Despite these interventions, there was no documentation in the electronic health record indicating when staff noticed the resident was missing, when a code silver was called, or when the search for the resident began. Additionally, there were no nursing progress notes documented from the time of the last elopement assessment until after the resident returned from the hospital, and no indication that the resident had any of the documented injuries prior to the elopement. Interviews with staff revealed that no one heard the wanderguard alarm sound at the time of the elopement, and the facility later discovered that the G-hall exit door had only one antenna, providing incomplete coverage for the double doors. The door company confirmed that the system was not providing full coverage and required an additional antenna for proper operation. The facility's policy required staff to know the location of residents under their care and to take appropriate action if a resident was missing, but these procedures were not effectively implemented in this incident.
Removal Plan
- Completed elopement risk assessments on all residents
- Conducted elopement drills with staff
- Educated all staff on the elopement procedure and high-risk behaviors
- Installed a second antenna on the G-hall double door exit
- Ensured proper operation of the elopement prevention system
- Increased the range of the elopement prevention system
- Changed door codes to prevent unauthorized exits