Elopement of Cognitively Impaired Resident Due to Unsecured Exit
Penalty
Summary
A cognitively impaired resident with a Brief Interview for Mental Status (BIMS) score of 5, indicating severe impairment, and a documented history of exit-seeking behaviors, was able to elope from the facility. The resident had previously been assessed as an elopement risk and was wearing a wanderguard bracelet. Despite these precautions, the resident was observed on camera footage moving from the second floor to the first floor, attempting to exit through a locked door, and then accessing an unlocked service hallway via double doors. The resident subsequently entered an unlocked laundry room, where an exit door without a lock, wanderguard sensor, or alarm provided direct access outside. The laundry door had been left unlocked by a staff member, and at the time, could only be locked with a key. The resident was last seen in the facility around 10 AM after receiving medication. The facility became aware of the elopement only after being notified by the resident's family member, who had been contacted by a bus driver at a nearby metro station. The resident, found at the bus terminal, expressed confusion about their location and requested assistance in returning home. The resident left the bus terminal before the family member arrived and was later located at a hospital in another district, having traveled a significant distance from the facility. Interviews and record reviews confirmed that the resident's care plan included interventions for wandering, such as providing diversions and structured activities. However, the physical security measures in place were insufficient, as the resident was able to bypass locked doors and exit through an unsecured area. The incident was determined to meet the federal definition of Immediate Jeopardy Past Non-compliance due to the facility's failure to prevent the elopement of a resident assessed as high risk.
Removal Plan
- Replaced the laundry entry door with a self-locking door.
- Bolted shut the exit door located inside of the laundry room where the Resident exited the facility.
- Reassessed all elopement risk residents and tested the wanderguard functionality on all residents with wanderguard bracelets.
- Completed in-service education for all staff on elopement, wandering, and monitoring.
- Environmental Service Director (EVS) completed in-service on safety procedure in laundry area.
- Ordered a maglock to secure and lock the double doors of the service hallway and installed it.
- Random audits to be performed on elopement risk residents and staff implementing interventions, with findings submitted to the QAPI committee for review and further recommendations.
- Director of Nursing (DON) and/or Assistant Director of Nursing (ADON) will audit for proper transcription of the wanderguard orders, elopement risk assessment presence, and care plan update for new residents identified to be a risk, with findings submitted to the QAPI committee for review and further recommendations.
- Engineering Director will audit the exit doors to ensure they are always locked, with findings submitted to the QAPI committee for review and further recommendations.