Failure to Prevent Elopement and Delayed Response to Missing Resident
Penalty
Summary
A cognitively impaired resident with a known history of wandering and a moderate risk for elopement, as documented in their care plan and risk assessments, was able to exit a secure second-floor unit despite wearing a wander guard device. The resident was first found by an LPN on the facility's first floor, asking another resident for directions. The LPN returned the resident to the second-floor common area but did not notify the assigned nurse or other second-floor staff of the incident. This lack of communication meant that staff were unaware of the resident's attempt to leave the secure unit earlier in the day. Later that afternoon, the resident pushed open a stairwell door on the second floor, proceeded down the stairs, and exited the facility through an exterior door. The stairwell door alarm sounded, but the unit secretary silenced the alarm without thoroughly checking the area or confirming the whereabouts of the resident. The unit manager was consulted for the alarm code but also did not investigate the cause of the alarm. As a result, the resident was able to leave the facility unsupervised and was not immediately detected as missing. It was not until several hours later, after staff noticed the resident was missing during rounds, that a search was initiated. The search was initially conducted by a single LPN and later expanded with additional staff, but facility administration and the DON were not notified until much later. The facility's elopement protocol was not enacted until several hours after the resident had left the premises. The resident was eventually found outside on facility grounds, having sustained injuries that required hospitalization. The failure to provide adequate supervision, respond appropriately to alarms, and enact the elopement protocol in a timely manner constituted a deficiency and resulted in an Immediate Jeopardy situation.
Removal Plan
- A headcount was performed to confirm that all residents were accounted for.
- Resident #2 was located and sent to the hospital for evaluation.
- Regional Plant Operations reviewed all doors and locking mechanisms and addressed variances.
- Nursing administration reviewed residents on wanderguard for appropriate orders and care plans.
- Elopement binders were reviewed to ensure that all residents at elopement risk were included.
- All staff were educated on procedures for elopement drill and announcement of Code Yellow.
- All staff were educated on the facility policies on wandering and elopement, and safety checks and supervision.
- Nursing staff were educated on rounding at the start of their shift and every 2 hours.
- Elopement drills were conducted.