F0689

J

Failure to Prevent Elopement of Cognitively Impaired Resident

Charlotte, North Carolina Survey Completed on 09-05-2025

Penalty

No penalty information released

Summary

A deficiency occurred when a cognitively impaired resident, who was care planned as an elopement risk and known wanderer with impaired safety awareness, exited the facility at night without staff knowledge. The resident was last seen at 9:00 PM and was discovered missing at approximately 9:30 PM. Staff conducted a search of the building before checking the back employee entrance, which required a keycode for exit and was not equipped with a wanderguard alarm. The resident was found outside, lying on his left side with his wheelchair on top of his lower back, approximately 30 feet from the exit door in a dark area near a dumpster. The area where the resident was found had a large crack in the pavement, which likely contributed to the wheelchair tipping over.

The resident had a history of heart failure, metabolic encephalopathy, and non-Alzheimer's dementia, and was assessed as severely cognitively impaired, requiring moderate assistance for transfers. The care plan included interventions such as distraction, increased supervision, and a wanderguard bracelet, which was to be checked every shift. However, the back employee entrance did not have a wanderguard alarm system, and staff interviews indicated that the resident may have followed someone out of the door or exited when the door was left open. The resident was found outside after being missing for approximately 15 minutes, and staff noted that he was confused and stated he was looking for the kitchen.

Interviews with staff and the DON revealed that the resident was known to follow staff closely and wander the facility in his wheelchair. The back employee entrance, used by staff for entry and exit, was not protected by a wanderguard alarm, and staff did not observe the resident exiting. The resident's elopement risk assessment was scored as low after the incident, and there was no documentation of wandering behaviors in the medical record prior to the event. The incident resulted in the resident being found outside at night, unsupervised, and in a potentially hazardous area.

Removal Plan

• Staff conducted a facility-wide search and located Resident #1 outside the employee exit door after being reported missing.
• A head-to-toe skin assessment, neurological checks, and range of motion were completed for Resident #1; no concerns identified.
• The Director of Nursing notified the on-call Nurse Practitioner and Resident #1's responsible party.
• The Regional Clinical Director reviewed Resident #1's care plan and physician orders to ensure proper documentation and interventions for wandering/elopement and wanderguard use.
• The Director of Nursing verified all doors were secure and locked, including performance test of wanderguard door.
• The Director of Nursing completed an elopement risk assessment for Resident #1 and verified wanderguard placement and battery function.
• Resident #1 was placed on 1:1 supervision.
• A 100% resident count was completed to ensure all residents were present.
• The Director of Nursing/Designee verified all residents with wanderguards had them in place and functioning.
• The policy and procedure for Wandering and Elopement was reviewed.
• The Maintenance Director checked all exit doors for proper functioning and performed a function test on the wanderguard door.
• Stop signs were placed on all exit doors as visual reminders for residents and staff.
• The Director of Nursing/Designee completed elopement assessments for all residents and evaluated interventions for those at risk.
• The Regional Clinical Director reviewed/updated care plans and NA's kardex's for all residents at risk for elopement/with a wanderguard.
• The Regional Clinical Director reviewed physician orders for all residents with wanderguards to ensure proper orders were in place.
• The Assistant Director of Nursing updated elopement books with pictures of residents at risk for elopement; books are maintained at nurse stations and reception.
• An elopement drill was conducted with all staff on duty using the facility Elopement Drill Documentation Audit Form.
• Staff were educated on the policy and procedure for Wandering and Elopement, including the elopement drill process and specific safety measures (e.g., not allowing residents to sit at exit doors, ensuring doors are closed/locked, monitoring whereabouts of wandering residents, reporting new behaviors, completing risk assessments, verifying wanderguard function, reviewing kardex, and responding to elopement/missing person).
• Education was added to the facility orientation program for all new hires, with validation by the Human Resource Director.
• An ADHOC QAPI Committee Meeting was held to review and approve the corrective plan and monitor its implementation.
• Root Cause Analysis was completed to determine the cause of the incident.
• The Director of Nursing/Designee and/or Human Resources Director/Designee will randomly observe staff entering/exiting employee entrance/exit doors (not wanderguard protected) to ensure compliance with safety protocols.
• The Maintenance Director/Designee will perform door checks on all exit doors and function tests on the wanderguard door.
• The Director of Nursing/Designee will verify wanderguards are functioning properly weekly.
• Elopement drills will be conducted on each shift, then additional drills monthly.
• The Director of Nursing/Designee will review all new admissions elopement assessments weekly to ensure proper interventions are implemented.
• The Director of Nursing/Designee will review progress/behavior notes to ensure wandering behaviors are addressed with proper interventions.
• The Director of Nursing/Designee and Maintenance Director will report audit results to the facility's QAPI committee meeting for review and recommendations.