Failure to Prevent Resident Elopement Due to Inadequate Assessment, Supervision, and Door Security
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of progressive neurological disease, diabetes, non-Alzheimer's dementia, anxiety, and depression was not properly assessed for elopement risk, nor adequately supervised, resulting in the resident eloping from the facility undetected for approximately 30 minutes. The resident, who had documented patterns of wandering, was able to exit the building through a 300 Hall door that did not function as intended, opening before the required 15-second delay. Staff failed to notice or respond appropriately to the resident's wandering behaviors, and the resident's care plan did not address wandering or elopement risk until after the incident occurred. Surveillance footage showed the resident wandering unsupervised throughout the facility for an extended period, including multiple attempts to exit the building. Staff were observed to be inattentive, with one LPN using a personal cell phone at the nurses' station and leaving the resident unsupervised. When the exit door alarm was triggered, staff did not conduct a head count or search outside, only resetting the alarm and looking out the window. The resident was later found outside in a ditch, inadequately dressed for the weather, complaining of cold and pain, and required transfer to the emergency department for evaluation. Documentation and interviews revealed that staff did not consistently review progress notes or update elopement risk assessments in response to changes in the resident's behavior. The resident's care plan lacked interventions for wandering prior to the incident, despite multiple documented episodes of nighttime wandering and exit-seeking. Staff were also not fully aware of or did not follow facility policies regarding supervision, response to exit alarms, and use of personal cell phones, contributing to the failure to prevent the elopement.
Removal Plan
- Elopement and Wandering Residents Policy reviewed and updated.
- All staff were made aware of mandatory all staff meeting regarding elopement policy and responsibilities during an elopement.
- Maintenance director inspected and tested 300 Hall exit door, accompanied by Surveyor.
- Additional education to all staff regarding proper functioning door alarms was initiated via text and in person.