Elopement Due to Staff Failure to Respond to Roam Alert System
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and dementia, who was identified as being at risk for wandering and elopement, successfully exited the facility without staff knowledge or intervention. The resident, who had a BIMS score of 4 out of 15 indicating cognitive impairment, was able to leave the skilled nursing facility (SNF) through the main exit while in a wheelchair. Video footage confirmed that the resident propelled himself to the elevator, traveled to the first floor, and exited the building without being stopped or supervised by staff. The incident was only discovered when a former employee, passing by the facility, noticed the resident outside and contacted the facility to alert them. At the time of the incident, staff responsible for monitoring the resident were not wearing their pagers, as they were on break, and did not respond to the Roam Alert system. The facility's policy required staff to use pagers and respond to alarms generated by the Roam Alert system, which is designed to notify staff when a resident at risk for wandering approaches a monitored exit. However, the staff failed to adhere to these protocols, resulting in the resident leaving the premises unsupervised. The resident was found outside the facility, near garages of an adjoining community, on a hot and humid day, and was returned to the facility by a staff member after being located by the former employee. Interviews with staff confirmed that the resident was last seen in the dining room and that his wandering behavior was known to staff. The main exit doors and alarm systems were in place, but the lack of staff supervision and failure to carry and respond to pagers directly contributed to the resident's elopement. The facility's own investigation and review of camera footage established that the resident was unattended when he left the SNF unit, and the alarm system notifications were not acted upon due to staff inattention and non-compliance with established safety protocols.
Removal Plan
- Member [R1] was returned to his apartment and immediately assessed by the Registered Nurse (RN)1 for any injury. No injuries were identified. Skin checks were initiated, and no injuries were noted. The family was notified. Medical Director was notified, and provider team completed an assessment.
- Safety checks were completed for the Member.
- The Community implemented 1:1 sitter immediately following the event.
- The Pharmacy consultant completed a medication review that was provided to the Medical Provider.
- The Administrator met with the family and updated the Member's care plan.
- Pending room availability and appropriateness, the Community has made the recommendation to move to Memory Care Assisted Living when appropriate.
- New elopement screening conducted for all residents by Unit Nurse.
- Residents assessed by Unit Nurse for ambulatory status and BIMS (Behavioral Interview for Mental Status) level of 5 or below. Roam Alert tags and corresponding physician orders obtained for qualifying residents.
- RN and C.N.A. assigned to Member [R1] were given immediate education on pager and call bell system use by the DON.
- DON (Director of Nursing) completed immediate reeducation to SNF staff and all community staff reeducated by CSA on Roam Alert and Pager Policy.
- Working pagers and radios verified for all staff.
- Maintenance staff assessed all exit points to ensure they were in proper working order.
- Elopement binders updated by ADON for all service lines.
- Maintenance increased the sound frequency on squealers at all SNF exit points.
- Maintenance reviewed [NAME]-Tone monitor volumes and ordered external speakers to increase sound of call bells/roam alerts.
- VP of Construction ordered Desk Top pagers that will be secured in hallways to provide additional alert of call bells/roam alerts.
- Upon admission, each resident will undergo elopement screening, including evaluation of ambulatory status by Unit Nurse, to then be reviewed by DON and/or ADON.
- Nursing staff will complete daily Roam Alert Tag audits to verify device functionality, proper placement, and skin integrity monitoring once per shift. Documentation will be maintained in the medical record and Roam Alert List.
- CSA, DON, and/or Designee will conduct audits daily, weekly, and monthly or longer until 100% compliance is met to ensure Roam Alert tags are functioning and in proper use. All negative findings will be corrected immediately.
- Involved Team Members will be reeducated immediately.
- Audit results will be reviewed in monthly Quality Assurance (QA) meetings for further recommendations.
- The facility's assessment will be updated to incorporate specific Roam Alert system requirements.
- All staff re-educated by DON and CA on elopement prevention policies, including the proper use of Roam Alert tags, immediate response protocols, and the importance of timely supervision.
- New hires will receive elopement training during orientation, and annual refresher training will be conducted for all staff by Administrative Nurse Staff.
- Family input will be incorporated into individualized care plans to enhance elopement prevention strategies at start of admission and will be carried out by the IDT.