Failure to Prevent Elopement and Inadequate Supervision of Residents
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for two residents identified as being at risk for elopement or accidents. One resident with Alzheimer's dementia, severely impaired cognition, and a history of repeated falls was assessed as high risk for elopement and was equipped with a wander detection device. Despite multiple prior incidents where this resident was found in or near stairwells and exit doors with alarms sounding, the resident was able to exit the facility undetected on two separate occasions. On both occasions, staff were either occupied providing care to other residents or did not fully investigate the source of the alarm, resulting in delayed recognition that the resident was missing. Documentation of required 15-minute checks was incomplete, and there was no evidence of additional interventions being implemented after the first elopement. Staff interviews revealed confusion about alarm response protocols, with some staff silencing alarms without fully searching the area or notifying supervisors as required by facility policy. Another resident with severely impaired cognition, multiple comorbidities, and independent use of a motorized scooter was allowed to move freely throughout the facility and its grounds. The resident was assessed as low risk for elopement and did not have a wander detection device. On one occasion, the resident left the facility grounds undetected and traveled approximately four miles away to a fast-food restaurant, where they were later found and returned by family. There was no documented plan to monitor or account for the resident's whereabouts when they left the building, and staff were unaware of specific monitoring expectations for residents using scooters independently on the grounds. The facility did not require the resident to notify staff or sign out when leaving the unit, and there was no restriction or supervision in place for off-campus mobility. Facility policies required staff to monitor residents' whereabouts, respond promptly to alarms, and notify supervisors in the event of a missing resident or elopement. However, staff interviews and documentation revealed inconsistent adherence to these protocols, including failure to expand searches beyond immediate areas, inadequate communication among staff, and incomplete documentation of supervision. These failures resulted in residents exiting the facility undetected, placing them at risk for serious harm and triggering Immediate Jeopardy and Substandard Quality of Care findings.
Removal Plan
- The facility's immediate plan was reviewed and accepted.
- 85% of staff had been educated on elopement risk and wander detection device door alarm response. The remaining staff will be educated prior to the start of their next shift or upon return from their leave.
- Staff education was verified onsite during interviews. Multiple staff including nursing, maintenance, housekeeping, and activities were interviewed.
- Staff were able to report content of education, confirmed the day they received the education, and the facility staff who presented the education.