Failure to Prevent Resident Elopement and Respond to Alarms
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and dementia, who had a history of repeated falls and unsteadiness, was found outside the facility lying on the ground in cold weather, dressed only in pajamas and slippers. The resident was admitted with diagnoses that included cognitive impairment and required supervision or assistance with walking, as well as the use of a bed alarm for safety. Despite these precautions, the resident was able to exit the facility without her walker or code alert sensor, and staff did not respond appropriately to alarms that were activated during the night. Staff interviews and record reviews revealed that alarms sounded during the early morning hours, but staff either misidentified the alarms or failed to investigate them properly. One staff member reported hearing an alarm around 4:00 AM but did not go outside to check, and the alarm was turned off without confirming the resident's whereabouts. Another staff member indicated that the door alarm was mistaken for a fire alarm and was silenced without further action. The resident was not accounted for until she was found outside by staff during morning rounds, at which point emergency services were called. The resident was subsequently transported to the hospital, where she was found to be hypothermic and diagnosed with an acute right subdural hematoma with midline shift, as well as multiple scalp hematomas and ecchymoses. The incident was further compounded by the fact that the resident's care plan identified her as at risk for wandering and safety concerns, and staff had been informed of her high fall risk and wandering behaviors. The failure to provide adequate supervision and to respond appropriately to alarms directly led to the resident's elopement and subsequent injury.
Removal Plan
- In-Service on Falls and Causes completed.
- In-Service on Safety and Supervision completed.
- Abuse and Neglect In-Service Training completed.
- Change in Resident Condition/Accidents and Incidents (Steps to Compliance) completed.
- Elopement In-Service and Training completed.
- In-Service and Training in reference to responding to Door Alarms completed.
- Door Alarm In-Service and Training conducted by Maintenance Director completed.
- In-Service on Choke Alarm completed by Maintenance Director.
- Fire Drill In-Service Training completed.
- Designee/Associate Administrator will educate ALL staff on Falls and Causes; Safety and Supervision of Residents; Abuse and Neglect; Change in Resident Condition; Elopement; Responding to Door Alarms; Door Alarms Checks (Maintenance), Choke Alarm, and Fire Drills.
- All employees will be educated on correct policies and procedures during orientation.
- Designee/Associate Administrator will complete an audit of in-services and training for Falls and Causes with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Safety and Supervision with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Abuse and Neglect with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Change in Resident Condition with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Elopement with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Responding to Door Alarms with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Door Alarm Checks with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Choke Alarms with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Fire Drills with results reported to the QAPI committee.