Failure to Provide Adequate Supervision and Prevent Elopement from Dementia Unit
Penalty
Summary
A resident with severe cognitive impairment and a history of wandering, as documented by a BIMS score of 3 and use of a wander guard, was able to leave the secured dementia care unit without staff knowledge. The resident exited through double doors, which were later found to have an inactive magnetic lock, and was discovered outside on a neighboring property by staff after an alarm had sounded for several minutes. Staff interviews revealed that the alarm was either faint or not heard by those on the unit, and that there was a delay in response as staff were engaged in other duties, such as medication administration and resident care. Multiple staff members, including LPNs, RNs, and CNAs, reported confusion regarding the source and urgency of the alarm. Some staff did not hear the alarm at all, while others heard it faintly but did not immediately act or communicate the situation to others. The alarm system's effectiveness was compromised by its location and volume, and the magnetic lock on the exit doors was found to be deactivated, possibly due to accidental contact with a switch by a medication cart. Staff were not immediately aware that the resident had left the unit, and a head count was only initiated after the alarm had been sounding for several minutes. The resident was found outside by a staff member and a member of the dietary team, with evidence of a fall reported by a neighbor. Upon return, the resident was assessed and found to have no injuries. The incident highlighted lapses in supervision, delayed response to alarms, and issues with the physical security systems intended to prevent elopement from the dementia care unit. Staff interviews confirmed that the required immediate response to alarms did not occur, and that the alarm and door locking systems were not functioning as intended at the time of the incident.