Failure to Prevent Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with a documented history of wandering, psychosis, anxiety disorder, paranoid schizophrenia, schizoaffective disorder, and epilepsy was not adequately supervised to prevent elopement. The resident was identified as being at risk for elopement and wandering, with an active care plan in place that included interventions such as a wander guard device, comfort measures, and environmental modifications. Despite these interventions, the resident was last seen by staff at approximately 5:30 PM and was later found outside the facility by first responders at 6:06 PM, indicating a lapse in supervision and monitoring. The resident's care plan and medical records indicated daily wandering behaviors and cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 9. On the day of the incident, the resident was observed ambulating in the hallway and did not exhibit exit-seeking behaviors at that time. However, the door alarm was activated at approximately 5:15 PM, and a CNA responded but assumed another resident with a wander guard had triggered the alarm. The CNA looked outside but did not see anyone and did not further investigate, resulting in the resident leaving the facility undetected. Staff did not become aware of the resident's absence until contacted by police, at which point a Code White/elopement was initiated. The resident was located approximately 700 feet from the facility and was transported to the hospital for evaluation. Interviews with staff confirmed that the wander guard was functioning, but no alarms were heard by the assigned nurse during the relevant time period. The incident revealed a failure to ensure adequate supervision and response to alarm systems for a resident at high risk of elopement.
Removal Plan
- Resident transported to hospital ER per EMS. Upon reentry, assigned nurse verified resident wander guard bracelet was in place, intact and functioning on right wrist.
- Assigned nurse performed body audit with no injury noted and documented body audit results in resident's medical record.
- Elopement Risk Observation repeated.
- Intervention: Wander guard bracelet to wrist and checked weekly.
- Maintenance Director/Designee performed an audit to ensure facility exits alarms were functioning.
- Wander guard audits completed.
- Residents at risk of elopement identified; placement and function of wander guards verified by DON for each.
- Elopement Risk Observations done in the past 90 days on current residents reviewed by nursing managers for accuracy; residents identified at risk will be reviewed for appropriate interventions.
- Educate facility staff regarding Wander guard System with emphasis on determining cause of alarm if sounding.
- New admissions will be reviewed in morning meeting daily as part of the clinical morning meeting process.
- Elopement Risk Observations will be reviewed for accuracy and interventions validated if indicated.
- Quarterly assessments will be reviewed as part of the MDS/Care planning process.
- The Director of Nursing will randomly audit a minimum of 5 Elopement Risk Observations weekly for 4 weeks then monthly for 2 additional months to validate accuracy.
- The Maintenance Director/designee will inspect facility doors with wander guard system 3 times weekly for 4 weeks then weekly for 2 additional months.
- The Facility Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with maintenance director to validate that doors are functioning properly.
- Ad hoc QAPI held to discuss the resident elopement and plan for improvement.
- This process will be reviewed in QAPI for a minimum of 3 months.