Failure to Prevent Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with severely impaired cognition and a high risk for elopement exited the facility undetected by staff. The resident, who had diagnoses including Non-Traumatic Brain Dysfunction and Alzheimer's Disease, was wearing a wander alert device and was supposed to be monitored every thirty minutes. Despite these interventions, the resident was last documented as seen at 11:00 PM, but managed to leave the building at 12:24 AM. The resident was later found and returned to the facility by police officers at 12:40 AM, having exited through a staircase and a gap in the fence behind the building. Staff failed to respond appropriately to the activated door alarm. Multiple staff interviews revealed that alarms were either not heard, were faint, or were silenced without a thorough investigation. One LPN heard the alarm but only checked the area for a resident known to wander, rather than conducting a full head count or searching all possible exit routes. Security staff also failed to physically check the exit doors after the alarm was triggered, relying instead on surveillance cameras and resetting the alarm remotely. Additionally, a CNA mistook pillows in the resident's bed for the resident being present, further delaying the realization that the resident was missing. The facility's policies required enhanced monitoring, functioning wander alert devices, and prompt response to alarms, but these were not effectively implemented. Staff did not conduct a head count or search all areas after the alarm was triggered, and communication lapses occurred between staff members regarding the alarm and the resident's whereabouts. These failures allowed the resident to leave the facility without detection, resulting in an elopement event.