Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision and Alarm Malfunction
Penalty
Summary
A resident with diagnoses including dementia with severe agitation, anxiety disorder, and hypertension was admitted to the facility and identified as a severe elopement risk. The resident was independent with ambulation and was equipped with a departure alert system on her wrist. Despite these precautions, the resident was able to leave the facility unsupervised and was later found at her daughter's house. The facility's incident investigation revealed that staff became aware of the resident's absence after a CNA questioned her whereabouts over the walkie, prompting a search of the facility and surrounding areas. Interviews with staff indicated that the resident had been displaying exit-seeking behaviors on the morning of the incident, including packing her bags and expressing a desire to go home. Although the DON and nursing staff were aware of her agitation, enhanced supervision such as 1:1 monitoring or frequent checks was not implemented. The departure alert system, which was intended to notify staff if the resident attempted to leave, did not activate when the resident exited the building. Staff had previously checked the system and believed it was functioning, but it failed to alert them during the incident. Further review showed that a caregiver from an adjacent apartment building encountered the resident outside the facility and, after a brief conversation, transported her to her daughter's house without notifying facility staff. The facility's policy required weekly checks of the departure alert system, but staff reported that checks were being done nightly and, after the incident, every shift. The failure to provide adequate supervision and ensure the proper functioning of the departure alert system resulted in the resident's unsupervised exit from the facility.