Failure to Prevent Resident Elopement Due to Inadequate Supervision and Lapses in Safety Procedures
Penalty
Summary
Staff failed to implement adequate interventions and supervision to prevent two residents from eloping without staff knowledge. In the first incident, a resident with a history of left femur fracture, alcohol abuse, tobacco use, and moderately impaired cognition (BIMS score of 12) was able to exit the facility through a patio door that was neither alarmed nor locked at the time. The resident, who required partial to moderate assistance for mobility and used a wheelchair and walker, left his wheelchair on the patio and walked unassisted to a nearby bar to purchase cigarettes. Staff only became aware of his absence after noticing his wheelchair was left unattended, prompting a search and eventual retrieval of the resident from the community. The resident was not wearing a WanderGuard device, and the patio door's alarm system was not in place at the time of the incident. The sign-out procedure was not followed, as the resident did not sign out or notify staff before leaving. In the second incident, another resident with epilepsy, mild cognitive impairment, Alpers Disease, and a history of wandering was found outside the facility without staff knowledge. This resident had a WanderGuard device, but it was placed on the right ankle instead of the left, which prevented the door alarm from activating when the resident exited through the main entrance. The resident was able to move independently in a wheelchair and stated he wanted to go outside to talk to another resident. Staff discovered the resident outside after being alerted by another staff member who saw him from a window. The door alarm system and WanderGuard device were later tested and found to be functional when used as intended, but the improper placement of the device allowed the resident to exit undetected. Documentation showed that elopement risk assessments and care plan updates were not consistently completed or updated in response to changes in the resident's condition and behavior. Interviews with staff and review of facility policies revealed that the sign-out and supervision procedures were not consistently enforced. Residents assessed as safe to leave independently were expected to sign out, while others required staff or family supervision. However, in both incidents, the residents exited without proper notification or supervision, and the required safety devices and procedures were either not in place or not correctly implemented. The facility's elopement/wandering policy defined elopement as any resident exiting the center without staff knowledge, but the policy was not effectively followed in these cases.