Failure to Respond to Elopement Alarm Results in Resident Leaving Facility
Penalty
Summary
A deficiency occurred when staff failed to respond promptly to a security elopement alarm, resulting in a resident eloping from the facility. The resident had been admitted with acute encephalopathy, severe impairment affecting judgment, and a history of wandering and elopement. Assessments indicated the resident was independently mobile, at high risk for both elopement and falls, and had a physician's order for a security bracelet to be worn on the right ankle. The care plan included interventions such as applying the security bracelet and checking its function and placement per protocol. On the day of the incident, the resident was last seen by staff outside his room during breakfast service. When the resident could not be located, a search was initiated inside and outside the facility. The security bracelet alarm at the front door was triggered, but staff did not respond to the alarm in a timely manner. The resident was eventually found at a family member's home approximately one mile away and was returned to the facility. At the time of his return, the security bracelet was still in place and functioning. Interviews with facility leadership confirmed that the alarm at the front door was sounding but was not answered immediately, as the receptionist who typically monitors the area was not on duty at the time. The facility had six other residents identified as high risk for elopement, all with physician's orders for security bracelets due to wandering or exit-seeking behaviors. Facility policies required adequate supervision and timely response to alarms for residents at risk of elopement, but these protocols were not followed during the incident.