Resident Elopement Due to Inadequate Supervision and Exit Alarm Failure
Penalty
Summary
A deficiency occurred when a resident with dementia, a history of elopement attempts, and a Wanderguard device was able to exit the facility without staff knowledge. The resident was found by hospital security staff lying in a hospital parking lot approximately one mile from the facility, after traveling with a walker along a multi-lane road under construction. Staff did not hear any door alarms, and the facility lacked camera surveillance to determine which door was used or how the resident exited undetected. The resident was missing for an undetermined period, and facility staff only became aware of the situation when contacted by hospital staff. The resident had been assessed as not at risk for elopement on a prior risk assessment, despite being cognitively impaired and exhibiting wandering behaviors. The Minimum Data Set (MDS) indicated severe cognitive impairment and wandering, and the care plan included interventions such as Wanderguard application and redirection. However, the resident was able to leave the facility, and staff interviews revealed inconsistent accounts regarding the last time the resident was seen and whether door alarms sounded. Some staff reported that residents had access to door codes, either by being given the codes to go outside and smoke or by observing staff entering them. Upon evaluation at the hospital, the resident was found to have sustained rib fractures, bruising, and swelling, but no new orders were issued upon return to the facility. Interviews with staff and the resident's Power of Attorney confirmed that the facility was unaware of the resident's absence until notified by the hospital. The facility's elopement policy stated that elopement should be prevented to the extent reasonably possible, but the failure to provide adequate supervision and ensure the effectiveness of exit alarms led to the resident's elopement and subsequent injury.