Failure to Prevent Elopement Due to Inadequate Supervision and Malfunctioning Alarm Systems
Penalty
Summary
A severely cognitively impaired resident with a history of exit-seeking and previous elopement attempts was able to elope from the facility. The resident, who had diagnoses including dementia and Alzheimer's disease and a BIMS score indicating severe cognitive impairment, was known to require supervision for locomotion off the unit and was identified as an elopement risk on their care plan. The resident was equipped with a Wander Guard (WG) device intended to prevent unauthorized exit by triggering alarms and disabling elevator and door access. On the day of the incident, the resident exited the facility through an employee entrance after using an elevator, both of which were supposed to be secured and alarmed for residents with a WG. The alarm system failed to activate when the resident used the elevator and exited through the employee door. A CNA observed the resident leaving but did not intervene, mistaking the resident for a visitor due to their appearance and the absence of an alarm. Multiple staff interviews revealed that the elevator and alarm system had a history of malfunctioning, with several staff members reporting prior incidents where the resident accessed the elevator and left the unit, as well as reporting these issues to management. However, there was no evidence that these concerns were effectively addressed or escalated to facility administration. The facility's policies required adequate supervision and a systemic approach to monitoring residents at risk for elopement, but staff practices and system failures allowed the resident to leave the building undetected. The resident was missing for several hours before being located by police and returned to the facility. Staff interviews indicated a lack of clear responsibility for supervising residents not assigned to them and inconsistent communication regarding malfunctioning safety systems. The failure to provide adequate supervision and maintain functional safety systems resulted in a situation of Immediate Jeopardy.
Removal Plan
- Resident was sent to the hospital for evaluation, returned to the facility, and immediately placed on 1:1 supervision that was maintained.
- Resident had a skin and pain assessment with no injury.
- The physician and family were notified.
- Resident's Wander Guard (WG) was checked every shift for placement and function.
- The facility's vendor serviced the WG system.
- Staff were stationed at employee entrance/exit until the system was repaired and the WG vendor increased the system's sensitivity.
- All residents with WG were checked.
- Updated resident photos for residents with WGs were posted in both elevators and employee entrance.
- All receptionists were educated on the process of buzzing employees in and out of the facility.
- All staff were educated on the facility's elopement policy, wandering binders and identification process.
- Elopement drills were conducted.