Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm Malfunction
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment exited the facility undetected. The resident, a male with diagnoses including diabetes, hypertension, gait and mobility abnormalities, and lack of coordination, had a BIMS score indicating severely impaired cognition. Although his initial care plan identified him as an elopement risk and included interventions such as distraction and structured activities, a prior wandering evaluation had not classified him as a wandering risk. On the evening of the incident, the resident was moved to a different room due to plumbing issues, and staff last observed him in his room before discovering him missing during routine rounds. Staff did not hear any door alarms when the resident exited through the east exit door, and the alarm system did not activate at the time of his departure. The resident was found outside the facility, across the street, wearing only socks and conversing with two individuals. Multiple staff interviews confirmed that no alarms were heard, and the door alarm was not triggered when the resident left. The maintenance supervisor and an external technician had serviced the door and checked the alarm system earlier that day, confirming it was operational at that time, but the reason for the alarm's failure during the incident remained unclear. The facility's policy required adequate supervision and timely response to alarms for residents at risk of elopement. Despite these protocols, the resident was able to leave the premises without detection or immediate staff response, as the alarm system did not function as intended. Staff were trained on elopement prevention and response, and regular elopement drills were conducted, but these measures did not prevent the incident. The deficiency was identified as past non-compliance, with immediate jeopardy beginning and ending within a specified timeframe.