Failure to Maintain Secured Unit Doors and Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that the resident environment remained as free from accident hazards as possible and did not provide adequate supervision and assistance devices to prevent accidents for one resident identified as an elopement risk. The secured unit's 800 hall door alarm and lock were not functioning properly, which allowed a resident with a history of elopement and multiple diagnoses, including vascular dementia, schizophrenia, and cerebral palsy, to exit the facility unsupervised. The resident was found outside in the parking lot by staff, and it was noted that the alarm on the door was not heard by staff at the time of the incident. Record reviews indicated that the resident had previously been identified as a high elopement risk, with documented incidents of leaving the facility and a care plan in place that included interventions such as 1:1 monitoring and frequent checks. Despite these interventions, staff interviews revealed inconsistent practices regarding door checks and alarm functionality. Several staff members, including CNAs and nurses, reported that they did not know why the secured unit door was unlocked or why the alarm was not functioning at the time of the incident. Maintenance and nursing staff also reported finding the door unlocked and the alarm not working on other occasions, raising concerns about the reliability of the security measures in place. Observations by surveyors further confirmed that the secured unit doors were found unlocked and unmonitored during their visit, with no staff present in the area and multiple residents standing near the unsecured doors. Staff interviews indicated a lack of awareness and communication regarding the status of the doors and alarms, as well as uncertainty about procedures when maintenance was being performed. Documentation logs indicated that the doors and alarms were supposed to be checked daily, but these checks did not prevent the deficiency from occurring.
Removal Plan
- Resident was returned to unit by CNA and assessed for injury by nurse working shift.
- Resident was placed on monitoring every 15 minutes until risk resolved.
- Maintenance supervisor checked all doors on the secured unit for alarms and proper functioning.
- The nurse completed head count to ensure all residents were safe on the unit.
- In-services started with secured unit staff and other departments to ensure unit remains secure, and residents remain safe.
- Administrator or designee will in service all employees that work or will work on secured unit prior to starting their shift so they are made aware of changes.
- Inservice consists of nursing making walking rounds to check the alarms doors for proper functioning at the beginning and end of each shift.
- Secured unit staff is to always have 2 staff members.
- CNA must report to nurse when taking break and nurse must inform other nurse on duty when she is on break and inform CNA staff when nurse is taking break and who to contact in case any issues occur.
- Administrator in-serviced environmental supervisor - laundry staff should be making rounds on secured unit and collecting soiled linen. This allows secured unit staff to remain on secured unit to provide supervision and care to residents.
- Laundry Staff were in serviced by environmental supervisor.
- In-services completed by Administrator with maintenance supervisor that she must remain on secured unit any time that maintenance is being done on secured unit and inform staff when maintenance is being done.
- Check the doors to make sure they remain locked.
- Administrator started in services with secured unit staff so they are aware the secured unit must always have 2 employees on the secured unit for resident safety.
- CNAs must report to nurse when taking a break to ensure appropriate staffing is on the secured unit.
- Nurses must inform other nurses on shift when they are taking their break and make sure the CNAs are aware, so they know who to contact if there are any issues while nurse is on break.
- In-services will be completed with staff prior to working shift on secured unit.
- Administrator started in services with secured unit nurses to ensure they are doing walking rounds at the beginning and the end of each shift to check the functioning of alarms and doors.
- Completing a head count at the beginning and end of each shift and report any issues found immediately.
- In-services will be completed prior to working shift on secured unit.
- Administrator and other department managers started Inservice on elopement.
- Facility must follow policy and procedure regarding elopement.
- Establish a monitoring system until risk has resolved and assign staff to sit one on one with resident until risk resolved.
- All nurses will be in serviced over changes to elopement policy and monitoring system prior to working shift.
- Elopement policy and procedure were revised to state a staff will sit one on one with resident until the risk of elopement has resolved.
- One on one form has been created, and staff must follow guidelines on monitoring form.
- Guidelines include staff must always remain within arm's reach, resident must remain in line of sight continuously, document observations every 15 minutes, report any changes in behavior to charge nurse.
- Administrator started in services with all staff and make sure staff is in serviced prior to starting shift.