Failure to Supervise Cognitively Impaired Resident Results in Elopement
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and ensure a safe environment for an ambulatory, cognitively impaired resident identified as an elopement risk. The resident, who had a history of dementia, severely impaired cognition (BIMS score of 0), daily wandering behaviors, and impaired safety awareness, was able to exit the facility through an alarmed door. The resident walked unaccompanied across the facility grounds, a residential street, and into a nearby hospital's ambulance garage. Staff were unaware of the resident's absence until notified by hospital personnel. The incident was precipitated by staff inaction following the activation of a door alarm. A dietary aide responded to the alarm, briefly looked outside in the dark, did not see anyone, and silenced the alarm without verifying the whereabouts of all residents. Other staff at the nurses' station did not further investigate the cause of the alarm or conduct an immediate headcount. The facility was experiencing alarm fatigue due to frequent non-emergency activations, particularly as the B-wing door was being used more often because of construction at the main entrance. This contributed to staff assuming the alarm was a false activation and failing to follow the facility's missing person policy, which required alarms to remain sounding until it was confirmed that no resident had left. The resident was later found by hospital staff, who contacted the facility. Upon return, the resident was assessed and found to have minor abrasions and redness on the palms, but was otherwise not in distress. The failure to properly respond to the door alarm and account for all residents resulted in the resident being unsupervised outside the facility, constituting a significant lapse in supervision and accident prevention.