Failure to Prevent Elopement Due to Disabled Door Alarms and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's dementia, confusion, and a history of wandering and falls was able to exit the facility unsupervised and was found across a busy street by a passerby. The resident, who was at significant risk for elopement and injury due to her cognitive impairment and physical limitations, left the building through a door on D hall. This door was equipped with mag locks and alarms, but both systems were found to be disengaged at the time of the incident, allowing the resident to leave without staff awareness. Interviews and record reviews revealed that the mag lock and alarm on the D hall door had been disabled, reportedly due to recent maintenance work. The Maintenance Director admitted to working on the door days prior and forgetting to reactivate the alarm system. Staff members, including those responsible for deliveries and supply, described procedures for unlocking and relocking the door, but on the day of the incident, the door was left unsecured and unalarmed. Multiple staff members confirmed that the red indicator light, which signals a locked door, was not on, and the door could be opened without triggering an alarm. The resident was not wearing any identification and was not immediately missed by staff, despite being seen walking the halls earlier in the day. The facility did not utilize wander guard devices for residents at risk of elopement. The incident was only discovered after emergency services contacted the facility, having been alerted by a passerby who found the resident outside. The facility's elopement policy required prompt investigation and search for missing residents, but the lack of functioning door alarms and supervision allowed the resident to leave undetected.
Removal Plan
- Resident evaluated at emergency room. No injuries indicated.
- Each Exit door was checked and secured by Manager on Duty.
- Resident returned to facility and placed on 15-minute checks.
- Physical Assessment Completed by Licensed Nurse with no injuries identified.
- Upon Resident return, Elopement Risk Assessment Updated to reflect current status by Licensed Nurse.
- Care Plan and resident profile updated by licensed Nurse.
- Maintenance Director was reeducated by the Administrator on validating doors are engaged and secure after any repair to door.
- Residents residing in the facility had an Elopement Risk Assessments updated by Director of Nursing/Designee.
- Residents identified as elopement risk were placed in the elopement binder and had care plans and profiles updated by Director of Nursing/Designee.
- Facility Staff were reeducated by the Director of Nursing/Designee on Elopement Policy and Process.
- Designated doors were set for facility staff to enter and exit the building.
- Any keys to disable door locks or alarms were placed with the Administrator.
- The identified side door will remain locked and alarmed at all times.
- Facility Staff were reeducated by the Administrator/Designee on the use of the designated doors for entry and exit.
- Any staff not receiving this education will receive prior to their next scheduled shift.
- Doors will be checked daily validating they are secure and properly functioning by Administrator/Designee for 3 months.
- Maintenance Director will validate exit doors are secure and functioning properly weekly.
- Elopement Drills will be completed with facility staff three times a month for 3 months.
- The Medical Director was notified of the contents of this plan and the Immediate Jeopardy.
- Ad Hoc QAPI was held.