Failure to Provide Adequate Supervision and Maintain Functional Exit Alarms for Resident at Risk of Elopement
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including toxic encephalopathy, chronic kidney disease, and a BIMS score of 0, exited the facility unsupervised. The resident was at risk for wandering and elopement, as documented in their care plan, and required increased supervision. Despite being equipped with a WanderGuard bracelet and having interventions in place, the resident was able to leave the facility without staff knowledge and was later found lying on the side of a road, confused and unable to answer questions, approximately 0.3 miles from the facility. The facility failed to ensure that all exit doors were properly alarmed and did not have a reliable system in place to verify that door alarms were functioning. The Director of Maintenance had been checking door alarms by visually observing keypads rather than actually testing the alarms, and it was discovered after the incident that at least one exit door alarm did not sound when opened, despite appearing to be armed. Staff interviews revealed that alarms were not consistently heard or responded to, and some staff were unsure how to operate or reset the alarms. Additionally, temporary magnetic strip alarms installed as a backup were found to be turned off or nonfunctional on several doors during the surveyor's inspection. The facility's investigation into the incident did not include interviews with staff or residents regarding the alarms, nor did it determine the root cause of the alarm malfunction. There was a lack of documentation and education regarding the proper functioning and monitoring of both the permanent and temporary alarm systems. The failure to provide adequate supervision and to maintain a reliable alarm system for residents at risk for elopement resulted in a finding of immediate jeopardy.
Removal Plan
- Ensure temporary alarms are in place and functioning and implement a process that includes increased frequency of door alarm monitoring.
- Review residents at risk for wandering.
- Educate all staff on the facility's elopement/wandering procedure and alarms, including monitoring and managing residents at risk for elopement or unsafe wandering and completing a wander risk assessment when a resident attempts to elope.
- Educate management staff on completing a thorough investigation.
- Implement audits to ensure wander risk assessments are completed, alarmed doors are functioning properly, and incidents are thoroughly investigated. Review audits with Quality Assurance and Performance Improvement (QAPI) members.