Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A facility failed to provide adequate supervision and prevent an accident hazard when a resident with severe cognitive impairment, traumatic brain injury, Parkinson's disease, and type 2 diabetes eloped from the facility during the night. The resident, who was identified as being at high risk for elopement and falls, wore a WanderGuard bracelet intended to prevent unsupervised exits. Despite this, the resident was able to leave the facility undetected sometime after being last seen at 9:40 p.m. and was not discovered missing until the following morning at 7:11 a.m. when staff could not locate her. The resident was found approximately 0.6 miles away from the facility, exhibiting hypothermia and abnormal vital signs, and was returned to the facility for assessment and care. The investigation revealed that neither the night shift nurse nor the CNA assigned to the resident's hall visualized the resident during their entire 8-hour shift. Staff interviews indicated a lack of clarity regarding which residents were at risk for elopement, as this information was not included on CNA assignment sheets or point of care tasks. Additionally, staff were inconsistent in their understanding and documentation of required checks for the WanderGuard device, and some were unsure of their responsibilities regarding its function. The facility's alarm system failed to alert staff when the resident exited, and subsequent testing showed that the alarm was not audible in all areas of the building. There was also uncertainty about whether a vendor had access to the door alarm bypass code, which may have contributed to the resident's ability to exit undetected. Further contributing factors included a malfunctioning security camera system due to a power outage, which prevented review of surveillance footage, and a possible issue with the front door's magnetic lock, which may not have latched completely. The facility's policies required regular assessment and communication of elopement risk, as well as monitoring and documentation of interventions, but these were not consistently implemented. The lack of direct resident checks, insufficient staff awareness of elopement risk, and failure of the alarm system collectively led to the resident's unsupervised exit and subsequent exposure to harm.