Failure to Prevent Resident Elopement Due to Inadequate Supervision and Unsecured Exits
Penalty
Summary
Facility staff failed to provide adequate supervision and maintain an environment free from accident hazards, resulting in a resident with cognitive impairments eloping from the facility for an undetermined amount of time. The resident had a history of alcohol abuse, disorientation, anxiety disorder, and other cognitive symptoms. Although an elopement risk assessment was completed on admission and a wander guard was ordered and documented as in place due to exit-seeking behaviors, there were lapses in ensuring the device was consistently used and functioning. Staff interviews and documentation revealed that the resident's wander guard was removed during a leave of absence and not replaced upon return, and staff did not notice its absence during routine checks. The facility's physical environment contributed to the deficiency, as several exit doors, including those leading to a courtyard and a side parking lot, lacked alarms or locking mechanisms to alert staff when opened. The maintenance director confirmed that certain doors did not have alarms at the time of the elopement, and staff were unaware when the resident exited. Additionally, the facility had not conducted regular elopement risk assessments as required by policy, with only two assessments documented for the resident despite ongoing risk factors. Staff interviews indicated a lack of awareness regarding which residents were at risk for elopement and which had wander guards in place. The incident was further compounded by the facility's failure to identify and address all unsecured exit points, as well as inconsistent implementation of elopement prevention protocols. The resident was able to leave the facility without staff knowledge, and was later found by police outside the facility, having been exposed to cold weather conditions. The facility had identified multiple residents at risk for elopement, yet at the time of survey, unsecured exits remained, placing all at-risk residents in jeopardy.
Removal Plan
- Installed screamer door alarms to the Unit 5 living room area door and the breezeway exit door to the courtyard.
- Ensured the doors will alarm when opened to alert staff of exiting.
- Education completed with all on duty staff and off duty staff via phone calls.
- All staff unable to reach via phone will be in-serviced before they come on duty.