Failure to Prevent Elopement Due to Inoperable Door Alarm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known risk for elopement was able to exit the facility unsupervised. The resident, who had diagnoses including vascular dementia with behavioral disturbance, psychotic disorder, and delusional disorder, was assessed as being at risk for elopement and wore a WanderGuard device daily. On the day of the incident, the resident was last seen by staff in the early morning, after which he was able to leave the building through a service hall door without staff noticing his absence immediately. The facility's policy required that residents at risk for elopement receive adequate supervision and that exit doors be equipped with alarms to prevent unauthorized exits. Despite these measures, the resident exited through a service door that was supposed to be alarmed. Staff initiated a search after realizing the resident was missing, conducting multiple checks inside the building before expanding the search outside. The resident was eventually found across the street on school grounds, having left the facility without injury. Interviews with staff confirmed that the resident's WanderGuard was functioning, but the door alarm did not sound due to damaged wiring. Further investigation revealed that the service hall door's alarm system had frayed wiring, which rendered the alarm ineffective and allowed the resident to exit undetected. The door in question was primarily used by dietary, maintenance, and laundry staff and was not a typical route for the resident. Facility leadership acknowledged that the damaged alarm wiring was likely caused by the high volume of equipment and personnel using the door. The failure to maintain the alarm system in working order and to provide adequate supervision for a high-risk resident led to the resident's successful elopement.
Removal Plan
- The wander guard for Resident DC was checked and found to be fully operational.
- A subsequent check of the wander guard revealed it was still functional.
- A comprehensive assessment of Resident DC was conducted, and it was documented that there were no injuries or any signs of distress.
- Resident DC was placed under 1-on-1 supervision for close observation and monitoring.
- A detailed inspection of the wander guard system at the facility's service hall exit uncovered that a wire had come loose, which directly impacted the alarm functionality of the door. This issue was promptly addressed, with the maintenance supervisor completing the necessary repairs.
- A backup alarm was installed on the interior door leading to the service area.
- A comprehensive check was performed on all other residents utilizing wander guards to verify their integrity and functionality, ensuring that no other residents were at risk of elopement.
- An accurate headcount of all residents was conducted to confirm that everyone was present and accounted for within the facility, ensuring the safety of all our residents.
- All exits were thoroughly inspected to verify that backup alarms were present and operational. This meticulous check confirmed the effective functioning of all backup alarms.
- An audit was carried out to identify residents who had undergone risk assessments related to potential elopement. This included a review of care plans to ascertain that interventions, such as the use of wander guards, were adequately addressed and implemented.
- Resident DC's care plan was updated to reflect the new risks associated with elopement incorporating specific interventions tailored to ensure his safety.
- The maintenance supervisor will perform inspections of the entire wander guard system and all backup alarms for every door to ensure they are functioning correctly.
- The wander guard alarm on 60 hall does not function, but the backup alarm functions and a stop sign has been placed over this door.
- All nursing staff across all shifts received training on resident safety protocols, specifically focused on checking alarms and monitoring wander guards. Any staff members on leave will receive this educational briefing upon their return to work.
- Agency staff will undergo training on these protocols before commencing their shifts.
- New hires will receive targeted training during their orientation regarding wander guard monitoring, alarm response procedures, and general resident safety.
- The Minimum Data Set (MDS) nurse will conduct audits of new admissions for elopement risk and ensure that appropriate safety interventions are put in place without delay.
- The maintenance supervisor will monitor alarm functionality daily for two consecutive months, moving to a weekly schedule thereafter. The results of this ongoing observation will be reviewed weekly by the facility administrator to ensure consistent compliance.
- Newly hired staff will receive dedicated training on topics related to wandering, elopement, and overall resident safety from the in-service coordinator during orientation.
- A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) has been implemented to systematically review and analyze all audit findings.
- The results of the alarm monitoring will be reviewed in the QA meetings monthly for three months, then quarterly, until it is determined that the deficient practice is not likely to recur.