Failure to Prevent Resident Elopement Due to Inadequate Supervision and Faulty Door Alarms
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple neurological diagnoses exited the facility unsupervised. The resident was able to leave through a door at the end of a hallway, descend eight steps, cross a parking lot and two traffic lanes, and reach the center median of a road with a 40 MPH speed limit. At the time of the incident, the resident's care plan did not include interventions for elopement risk, and her most recent elopement assessment indicated she was not at risk for elopement. Staff statements and documentation confirmed that the resident was not being directly supervised when she left the building, and the door alarm system was not functioning reliably, as it would automatically shut off after 15 seconds and was not always audible to staff in nearby offices. Interviews with staff revealed that prior to the incident, the facility's elopement prevention measures were insufficient. Staff were not alerted to the resident's exit until a passerby notified them after seeing the resident in the road median. The alarm system on the exit doors was described as inconsistent, with alarms sometimes failing to sound or being inaudible. Staff also reported that the resident was not previously identified as high risk for elopement, and her care plan did not reflect any elopement interventions. The lack of supervision and inadequate alarm system allowed the resident to leave the premises unnoticed. Documentation showed that the resident was able to walk with supervision or touching assistance and had a history of cognitive impairment, including a BIMS score indicating severe impairment. Despite these risk factors, the facility did not have appropriate elopement precautions in place for her. The incident was identified as Immediate Jeopardy, as the resident was exposed to significant danger by being unsupervised outside the facility and in proximity to a busy road.