F0689

J

Failure to Prevent Elopement of Cognitively Impaired Resident Due to Lapses in Supervision and Wander Guard Use

Canton, Ohio Survey Completed on 10-20-2025

Penalty

No penalty information released

Summary

A severely cognitively impaired resident, with diagnoses including senile degeneration of the brain, anxiety disorder, encephalopathy, and type 2 diabetes mellitus, was identified as high risk for wandering and elopement upon admission. The resident's assessments indicated severe cognitive impairment, disorientation, and a history of wandering, with interventions including the use of a wander guard device. On the night of the incident, the resident had experienced a seizure and was transported to the hospital by paramedics, during which the wander guard was removed. Upon the resident's return from the hospital, there was no verifiable evidence that the wander guard was reapplied, and the nurse responsible for re-admission was unaware of the need for the device.

Throughout the night, staff observed the resident wandering the building, attempting to redirect him with snacks, television, and conversation, but were unsuccessful in keeping him in his room. Multiple staff members noted the resident's persistent wandering and attempts to exit, with door alarms sounding at various times. Despite these behaviors and the resident's known risk, staff did not verify the presence or function of the wander guard, and there was no documentation indicating it was reapplied after the hospital visit. Additionally, staff allowed family members of other residents to enter and exit the facility using the door code without staff assistance, which created an opportunity for the resident to follow someone out of the building.

The resident ultimately exited the facility unnoticed during the early morning hours and was found by a concerned citizen walking in the middle of the road, approximately 0.55 miles away from the facility, dressed in a t-shirt, pajama pants, and without shoes, in 46-degree weather. Facility staff were unaware of the resident's absence until notified by local law enforcement. The facility's failure to ensure the wander guard was in place and to provide adequate supervision and control of exit doors directly led to the resident's elopement.

Removal Plan

• Local law enforcement called facility and spoke with Licensed Practical Nurse (LPN) #107 to notify about Resident #12 being found and taken to the hospital.
• LPN #107 and Registered Nurse (RN) #108 completed a head count of all residents to ensure all were present and accounted for.
• LPN #107 attempted to notify Resident #12's Responsible Party and left a message.
• LPN #107 notified RN Manager #109 of Resident #12 leaving the facility and being taken to the hospital; RN Manager #109 notified the Administrator.
• RN Manager #109 attempted to contact Resident #12's Responsible Party and left a message.
• RN Manager #109 called and spoke with the hospital nurse for an update on Resident #12.
• RN #111 spoke with Resident #12's Responsible Party and notified them of the incident.
• Resident #12 returned to the facility accompanied by paramedics; RN #111 obtained vital signs and assessed Resident #12.
• Resident #12's wander guard was placed back on by RN #111 and Resident #12 was placed on one-on-one (1:1) supervision.
• Facility staff were educated on the Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions were in place for residents with exit seeking behaviors, ensuring interventions were put back in place when residents returned from the hospital, and not giving residents or families the door code.
• RN #101 audited resident orders and care plans for wander guards; any variances were corrected immediately.
• Receptionist #114 and Maintenance Director #115 audited all residents with wander guards for functioning, placement, and expiration; all were placed properly, functioning appropriately, and not expired.
• Maintenance Director #115 audited all exit doors and the wander guard system at all doors to ensure proper function.
• RN #101 audited current resident progress notes to ensure if behaviors consistent with exit seeking were noted, then residents had appropriate interventions in place.
• Resident #12's Nurse Practitioner (NP) #116 was notified of Resident #12 leaving the facility and being taken to hospital by law enforcement with return to facility.
• Administrator audited the facility records of exit door function checks.
• ADON #103 completed elopement and wandering risk assessments on all in-house residents.
• An elopement drill was completed by Maintenance Director #115.
• An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the facility correction plan including ongoing compliance.
• ADON #103 educated all current resident responsible parties via phone that they were to ensure staff let them in and out the doors when the front door was locked and should not enter the code themselves or let anyone else out without staff assistance.
• SecureCare was called and the front door code was changed by Maintenance Staff #117.
• The Care Conference form was updated by the Administrator to include education for new families and a reminder for others to request staff assistance with doors when locked, not put in code themselves or assist anyone else out of facility.
• Resident #12's care plan was updated by RN #101 to include wandering and elopement risk with interventions including 1:1 as needed, monitor and report changes in behaviors, orient to new surroundings, provide diversional activities of interest as needed, redirect as needed, and wander guard with placement and function checks as ordered.
• Nursing staff would monitor the effectiveness of interventions for Resident #12 by reviewing point of care (POC) documentation and conducting a review for weekend POC.
• CNAs would report behaviors to the charge nurse if behaviors were not resolved with interventions.
• 1:1 (staff) supervision would continue for Resident #12 until discharge.
• If a call off occurred for a person doing 1:1 supervision, the Administrator would be immediately notified and re-assign floor staff, management staff, or other department staff to cover 1:1 as appropriate. The Administrator would oversee 1:1 coverage scheduling.
• All new hires and agency staff would be educated regarding the facility's Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions are in place for residents with exit seeking behaviors, ensuring interventions are put back in place when residents return from the hospital, and not giving residents or families the door code.
• The Administrator or designee would review all door checks to ensure all doors were checked and functioning appropriately. All variances would be corrected upon discovery and education/follow-up would be provided as deemed necessary.
• Maintenance Director #115 or designee would conduct elopement drills to ensure staff respond accordingly. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
• The DON or designee would assess all residents with wander guards to ensure proper placement, function and expiration. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
• The Administrator or designee would audit the wander guard system and resident accessible exit doors to ensure they were functioning properly to ensure all doors were intact and functioning properly, including alarm. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
• The DON or designee would complete elopement and wandering risk assessments for facility residents to ensure no changes in behavior patterns or acute changes in condition affecting mental status were present placing residents at risk for elopement and ensuring that appropriate and effective interventions were in place. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
• The DON or designee would audit progress notes to ensure any residents with behaviors that increase risk for elopement or exit seeking have appropriate interventions in place.
• The Administrator or Designee would interview visitors to ensure visitors were aware they were not to enter door codes when the door was locked and should wait for staff assistance to exit facility, as well as not let anyone else out without staff assistance.
• The facility Quality Assurance (QA) committee would review audits to ensure compliance. Variances would be corrected immediately upon discovery and education provided.
• Results of these audits would be reported to the facility quality assurance committee. Ongoing compliance would be maintained by recommendations of the facility quality assurance committee.