Failure to Prevent Elopement Due to Inadequate Supervision and System Malfunction
Penalty
Summary
The facility failed to provide adequate supervision to a severely cognitively impaired resident with a known history of wandering and elopement risk, resulting in the resident eloping from the facility. The resident, who had dementia, epilepsy, a history of falls, and a BIMS score indicating severe cognitive impairment, was last seen by staff near the nurse's station and was later found outside the facility by members of the public. The resident was wearing a wander guard, but exited through an unsecured back door in a construction area where the wander guard system was not operational due to a malfunctioning pin pad and disconnected power to the magnet lock. The required daily check of the door alarms had not been completed by the Manager on Duty prior to the incident. Staff interviews and facility records revealed that the resident had been identified as an elopement risk days prior, with a care plan and wander guard in place. However, the resident was able to leave the building through a series of unsecured and unsupervised areas, including a construction zone with an unzipped dust barrier and unlocked doors, ultimately reaching a sidewalk adjacent to a highway. The wander guard system did not alert staff to the resident's exit, and the malfunction was only discovered after the elopement occurred. The facility's elopement and wander guard policies required regular maintenance and testing of the system, as well as supervision in the event of equipment malfunction, but these procedures were not followed. Additionally, the facility failed to ensure that all staff were aware of which residents were at risk for elopement. A second resident, also with severe cognitive impairment and a history of wandering, was not recognized by some staff as a wanderer or as wearing a wander guard. The Neighborhood Watch list, which identified residents at risk for elopement, was not consistently updated or communicated to all staff, leading to confusion and lack of awareness about residents requiring increased supervision. This lack of communication and oversight contributed to the deficient practice in preventing elopement.
Removal Plan
- Resident #2 was located and brought back in building, wanderguard was functional, the resident was assessed with no injuries and placed on 1:1 supervision.
- The Director of Maintenance checked doors, elevators, and wanderguard systems to confirm functional, and identified a possible exit in a non-residential area and secured with alarm.
- The facility began an investigation, and wanderguard devices were tested.
- The Neighborhood Watch list with residents' photos was updated.
- An elopement drill was conducted.
- Certified Nursing Aide (CNA) assignments were updated to include identification of residents at risk for elopement.
- All staff were educated on elopement process.