Failure to Prevent Resident Elopement Due to Unmonitored Exit and Non-Functioning Door Alarm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of strokes, and impaired safety awareness eloped from the facility. The resident was able to exit through a door in Unit 3 vicinity hall 100, which was not properly monitored or secured during an EMS response for another resident's medical emergency. The door's 15-second delay alarm system was not functioning correctly, and staff were unaware of the malfunction. The resident was last seen in her room by staff and was later found missing during routine rounds. The facility's records indicated that the resident was considered low risk for elopement, and there was no prior evidence of exit-seeking behavior, but she had a history of confusion and required redirection when wandering into previous rooms. Staff interviews revealed that during the time of the emergency involving another resident, the exit door used by EMS was not monitored, and staff attention was diverted. Multiple staff members, including the DON, LVNs, and CNAs, stated they were not aware that the exit door alarm was not working. Additionally, it was observed that residents with high cognitive scores had access to the keypad code for the exit doors, and there was no list of which residents knew the codes. The facility's logbook for door checks was incomplete, and not all exit doors were being checked as required by policy. The resident was missing for several days, during which time she was exposed to cold weather and missed her medications, before being found by law enforcement on a bus and taken to the hospital. The facility failed to follow its own elopement prevention and response policies, which required all exit doors to have functioning alarms and to be checked each shift, as well as monitoring of doors during EMS entry and exit. The responsible party (guardian) was not notified immediately of the resident's elopement, and there was a delay in communication. The deficiency was identified as Immediate Jeopardy due to the failure to provide adequate supervision and maintain a safe environment, resulting in the resident's elopement and exposure to potential harm.
Removal Plan
- Resident #8 was readmitted to a room across from the nurse's station for better monitoring and placed on one-to-one supervision to assure safety and monitor for elopement tendencies.
- Implement a check procedure with nursing to document Resident #8's presence.
- Activities and meal attendance for Resident #8 will be completed with an escort.
- All exit doors were checked by Maintenance to confirm alarms were operational and documented.
- Any EMS arrival requires a dedicated staff member posted at the door to maintain supervision during the entire EMS presence in the building.
- A full resident headcount was completed by the DON to ensure no other residents were missing or unaccounted for.
- All on-duty staff were re-educated on elopement prevention policy, door-monitoring requirements during emergencies, and that exit codes will not be shared with residents or visitors.
- Random competency quizzes will be completed.
- Exit door audits will be completed.
- Review of elopement risk assessments for all residents, including Resident #8.
- Full staff retraining on elopement procedures, supervision, and emergency response for all active personnel, with PRN or leave staff retrained prior to return.
- Maintenance audit of all door alarms will be completed.
- Administrator/DON will audit 100% of EMS entry/exit logs, door monitoring logs, and elopement assessments.
- Mock elopement drills will be completed.
- All audits and drill results will be reviewed in Standards of Care meetings, with immediate corrective action for any deviations.