Failure to Prevent Elopement and Ensure Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement safety interventions to prevent elopement for a resident with severe cognitive impairment and a history of wandering and exit-seeking behaviors. The resident, who had diagnoses including vascular dementia and required assistance with activities of daily living, was identified as being at risk for elopement and had a care plan in place that included the use of a wander guard bracelet and regular checks. Despite these interventions, the resident was able to exit the building unsupervised and was later found outside by a staff member. Multiple door alarms were activated during the evening of the incident, but staff responses were inconsistent and ineffective. Staff were unable to interpret alarm panels due to the lack of posted zone identifiers, and alarms were repeatedly silenced without confirming the safety of all residents. No immediate headcount or licensed nurse assessment was completed, and the facility's Code Green procedure was not initiated. Communication among staff was poor, with conflicting accounts of the event and a lack of clarity regarding which resident was missing and which door had been used for the exit. The incident was not reported to administration or investigated until approximately 30 hours after it occurred. During this time, no new interventions were implemented to ensure the safety of other residents at risk for elopement. The facility's failure to respond effectively to multiple alarms, identify the missing resident in a timely manner, and follow established elopement protocols resulted in a breakdown of supervision and safety systems for residents identified as being at risk for elopement.
Removal Plan
- Complete a skin assessment on the resident.
- Ensure the resident's wander-guard bracelet is intact and functional.
- Initiate fifteen-minute safety checks.
- Update the resident's care plan to reflect current interventions.
- Review and revise the facility's elopement policy and door alarm protocol.
- Educate all staff on elopement prevention, wandering, resident safety, and identification of alarm zones.
- Check all wander-guard door boxes and door alarms for proper functioning.
- Check all residents with wander-guard bracelets for proper device placement and functionality.
- Complete audits to ensure no other residents are affected by alarm or supervision concerns.
- Complete new elopement risk assessments for all residents.
- Review and update elopement binders and resident care plans.
- Initiate door checks on each shift to be completed by the Maintenance Director or designee.
- Conduct elopement drills by the Maintenance Director or designee.
- Review results of education, audits, and drills at the next QAPI meeting for continued monitoring.