Failure to Prevent Elopement Due to Inadequate Supervision and Ineffective Door Alarms
Penalty
Summary
A deficiency occurred when a resident with a history of vascular dementia, anxiety, and disorganized thinking was not provided with adequate supervision to prevent elopement. The resident had a documented pattern of exit-seeking behavior, as noted in multiple progress notes over several days, including attempts to open doors, triggering door alarms, and verbalizing intentions to leave. The care plan identified the resident's cognitive impairments and directed staff to orient the resident, protect from self-injury, and maintain a calm environment, but did not specify enhanced supervision or elopement precautions despite the ongoing exit-seeking. On the day of the incident, staff failed to account for the resident during shift change. There was confusion among CNAs regarding the resident's whereabouts, with assumptions made that the resident was in another unit. The resident was ultimately discovered missing after a CNA could not locate her in the building. Staff initiated a search, and the resident was found by a dietary staff member at a local grocery store over a mile away, standing partially in the road. The resident was returned to the facility without injury, but interviews revealed that staff did not consistently perform end-of-shift rounds or communicate effectively during shift reports, and that the resident had previously exited the building without being noticed. Facility observations and staff interviews indicated that the exit doors were equipped with coded keypads and alarms, but the alarm volume was minimal and not always audible from resident rooms. The resident was able to exit through a door by holding the lever for 15 seconds, as indicated by signage. Staff reported that the facility did not utilize a Wanderguard system, and that some doors could be opened if leaned on. The lack of effective supervision, insufficient alarm audibility, and inconsistent staff practices contributed to the resident's unsupervised exit from the facility.
Removal Plan
- A body audit was completed on Resident #4 upon return to the facility.
- Resident was immediately placed on 15 minute checks.
- Staff in service on elopement prevention and CMS guidelines were conducted.
- Head count conducted for the entire facility following the elopement.
- Maintenance director checked all doors throughout the building.
- A professional contractor was contacted to complete a facility-wide inspection of all door alarms and perform any necessary corrective work.
- The contractor will also evaluate and adjust alarm volume upward, as needed, to ensure maximum audibility throughout the facility.
- Elopement risk assessments completed on admission, quarterly and with significant changes.
- Elopement drill conducted.
- All new hires receive dementia management training.
- The nursing department receives further education on dementia/wandering residents annually and as needed throughout the year.
- Door alarm inspections will be increased to daily from weekly by the maintenance staff.
- Inservice to be provided to staff regarding any issues with the doors/alarms must be reported directly to the Director of Nursing or the Administrator.
- The facility has set the TELS system, used to document completion of the monitoring, to alert the administrator via email and mobile application that the task was completed.
- The administrator will take findings to QAPI committee monthly for three months and quarterly thereafter until the issue is deemed to require no further issue.