Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A cognitively impaired resident with diagnoses including subarachnoid hemorrhage, dementia, anxiety, and insomnia, and who was identified as high risk for wandering, exited the facility unsupervised. The resident, who used a wheelchair and wore a Wander Guard, was able to open a delayed-egress door that alarmed upon activation. Despite the alarm sounding, no staff responded immediately. The resident propelled herself across the driveway and into the city street, traveling approximately 200 feet before being noticed by staff. At the time of the incident, the nurse on duty heard the alarm and saw the resident exiting but did not immediately respond to the door. Instead, the nurse returned to the nurse's station and only later proceeded down the hall, at which point the resident was already outside in the street. The nurse called for assistance, and a CNA responded, retrieving the resident and bringing her back inside. The facility's video footage confirmed that the resident was outside unattended for approximately three minutes and that the nurse did not maintain continuous visual observation of the resident during the elopement. The resident's care plan documented her as an elopement risk and included interventions such as structured activities, reorientation strategies, and signage on facility doors. However, the care plan was not effectively implemented, as staff failed to respond promptly to the door alarm and did not prevent the resident from leaving the premises. The facility's policy required immediate response to alarms and supervision of residents at risk for elopement, but these procedures were not followed, resulting in the resident's unsupervised exit.
Removal Plan
- Immediate 1:1 supervision with behavior monitoring were initiated for R7.
- Nursing counseling was provided to LN H and her supervisor on the facility's Elopement and Wandering policy.
- Facility-wide education was implemented regarding the immediate retrieval of a resident during an exit attempt in conjunction with a review of the elopement policy.
- Plan of care meetings were held with R7's family.
- A Behavior Monitoring log was initiated to assess for exit-seeking behaviors, restlessness, or patterns warranting intervention.
- The facility pharmacy consultant performed a focused medication review related to the resident's increased exit seeking to find family, brief recall of direction, and intermittent agitation.
- Administration contacted their door lock company to assess and repair any issues identified.
- The Director of Nursing submitted a report to the Kansas State Board of Nursing regarding LN H's failure to communicate that she did not have eyes on R7 the entire time of the elopement.