Failure to Prevent Elopement Due to Lapses in Supervision and Door Alarm Protocols
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dementia, Alzheimer's disease, and hypertension eloped from the facility at night. The resident was ambulatory and had been assessed as a moderate risk for elopement, with a care plan in place that included frequent rounding and monitoring. On the evening of the incident, the resident was observed wandering throughout the facility and was last seen following staff members down the hall. The resident subsequently exited the building, crossed a busy five-lane road, and was found at a bus stop by an off-duty CNA. The investigation revealed multiple failures in the facility's supervision and safety protocols. The inside door to the front lobby had a charm and keypad, but the wandering alert system and electronic magnetic lock were not functioning. The front door was secured only by a deadbolt and lacked an alarm or delay system. The receptionist, whose desk was adjacent to the front door, left her post to purchase dinner and did not activate the foyer alarm as required by protocol. Additionally, the nurse responsible for setting the keypad at 8:00 PM did not do so, and this lapse was not verified by another staff member as required. Staff interviews confirmed that the alarm was not set, and the resident was able to leave the facility undetected during a shift change. Documentation and staff statements indicated that the facility had an elopement protocol and policies requiring monitoring of residents at risk for wandering, regular checks of door alarms, and verification of alarm activation. However, these protocols were not followed on the night of the incident. The receptionist did not arm the foyer door, the nurse did not verify or set the alarm, and there was no effective monitoring of the resident during the critical period. The facility's own root cause analysis identified the failure to set the foyer alarm and the absence of the receptionist at the front desk as the primary causes of the elopement.