Failure to Prevent Elopement and Inadequate Response to Alarms
Penalty
Summary
The facility failed to provide adequate monitoring and supervision to prevent elopement and respond appropriately to door and Wanderguard alarms for two residents identified as being at risk for elopement. One resident with severe cognitive impairment and a history of exit-seeking behavior was able to exit the facility through an employee entrance door after following a CNA who was leaving for break. The resident was found outside by another resident approximately ten minutes later, attempting to re-enter the building. Staff did not respond to the door alarm in a timely manner, and there was confusion among staff regarding the source and significance of the alarms, with some staff assuming the alarms were related to shift change and not investigating further. The resident who eloped had a documented history of wandering, elopement risk, and severe dementia, with care plans and assessments indicating the need for close supervision and the use of a Wanderguard device. Despite these interventions, the resident was able to leave the building unsupervised. Staff interviews revealed a lack of familiarity with alarm systems, Wanderguard functionality, and facility protocols, particularly among agency staff and new hires. There was also a lack of clear documentation and communication regarding the checking and maintenance of Wanderguard devices for another resident at risk for elopement, with no evidence that required checks were being performed or documented. Facility policies and orientation materials did not provide sufficient guidance on responding to alarms, identifying alarm sources, or the use of Wanderguard devices. Agency staff were not consistently oriented to these procedures, and there was no verification that required orientation or competency checks had been completed. The combination of inadequate staff response, insufficient training, and lack of documentation contributed to the failure to prevent the elopement and ensure the safety of residents at risk.
Removal Plan
- Resident #101 was placed on 1:1 supervision until further interventions could be implemented. Law Enforcement, physician and Director of Nursing notified. The Administrator notified the brother of the incident.
- The EVS (environmental services) Director assessed the facility doors for proper function of the alarm system.
- The Administrator reviewed the elopement binder.
- The Elopement and Wandering Policy was reviewed by the facility Administrator.
- Assessments were completed on the resident to ensure the resident did not experience any adverse effects of the elopement, including skin assessment, pain assessment and vital signs were obtained.
- Care Plan was updated with proper interventions to reduce future risk of elopement.
- The facility audited residents who were determined to be at risk for elopement. The Facility completed an elopement risk observation, reviewed and/or updated the elopement care plan and ensured appropriate interventions.
- Resident #104's orders were put in place to ensure Wanderguard functionality would be checked.
- Agency LPN's and staff Cena's were educated by the DON, Maintenance and Administrator on the facility's policy on elopement and wandering. An elopement drill was completed.
- Education of elopement and wandering policy was initiated; any staff member who did not receive education will receive education prior to the start of their next shift.
- All Staff have been educated.
- Agency Staff have received the education prior to working their next shift.
- Agency staff education will include an in-person orientation with new agency staff that will include how to determine where the alarm is coming from, how the doors function, Wanderguard usage, door codes, and expectations for responding to a door alarm.