Failure to Prevent Elopement Due to Inadequate Supervision and Non-Functioning Door Alarms
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents, specifically related to elopement risks. Multiple observations revealed that door alarms were either not functioning, turned off, or not responded to in a timely manner. On several occasions, doors leading to the outside were found cracked open or could be opened without triggering an alarm, and staff were observed not checking on residents who were at risk of elopement. These lapses allowed a severely cognitively impaired resident, who was identified as an elopement risk, to repeatedly leave the facility unsupervised, including incidents where the resident was found outside in unsafe conditions such as in the middle of the road or inside a visitor's van. The resident in question had a history of alcohol-induced dementia, Wernicke's encephalopathy, and chronic kidney disease, and was documented as being ambulatory and prone to wandering. Despite being placed on frequent checks and having a wander guard, the resident was able to exit the facility multiple times. Staff interviews confirmed that the resident was able to find ways to leave the building, sometimes with the assistance of visitors or by exploiting malfunctioning or inaudible alarms. Documentation also indicated that staff were aware of the resident's repeated elopements, but there was a lack of consistent monitoring and timely response to alarms, and the resident's legal guardian was not notified of these incidents. Another resident, also identified as an elopement risk with cognitive impairment and mobility limitations, was able to exit the facility on multiple occasions. This resident was found outside in inclement weather, inadequately dressed, and required staff intervention to be brought back inside. Staff interviews and progress notes indicated that alarms did not always sound when doors were opened, and there was uncertainty about how long the resident had been outside. The facility's own logs did not consistently document these incidents, and staff acknowledged that some doors were routinely left unalarmed for convenience, further contributing to the risk.
Removal Plan
- Facility Elopement Policy was reviewed by Regional Director of Operations and was found to be in compliance with state and federal regulations.
- Facility Administrator or designee initiated in-servicing for all staff on the elopement policy and procedures. In-servicing will be completed by the start of each staff members next shift.
- Facility Administrator or designee initiated in-servicing for all staff on ensuring all staff are monitoring door alarms and responding immediately. In-servicing will be completed by the start of each staff members next shift.
- Maintenance Director or designee will conduct an audit of all facility door alarms and to be completed weekly to ensure they are adequately functioning and audible to staff areas.
- Administrator or designee to conduct Elopement Drill weekly x4 weeks to ensure monitoring and compliance.
- The Administrator or designee will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand elopement policies and procedures.
- IDT team (Admin, DON, SSD, MDS, DM) has assessed R4 and care plan updated to reflect new interventions for R4 being placed on the locked unit.
- IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents for the potential to elope and care plans updated to reflect interventions to protect residents from elopement.
- R4 was placed on the locked unit.
- All facility exit door keys were removed and placed in secured location.
- Facility Administrator or designee initiated in-servicing for all staff to not turn off door alarms. In-servicing will be completed by the start of each staff members next shift.
- Maintenance Director replaced the door lock to 300 Hall door to courtyard and is functioning properly.