Elopement Through Window Due to Inadequate Supervision and Nonfunctional Window Alarm
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise a cognitively impaired resident and to ensure the environment was free from accident hazards, resulting in an elopement through a bedroom window. The resident was an 83-year-old female with advanced dementia and a care plan identifying her as at risk for elopement and unable to make decisions regarding her safety. Her care plan included approaches such as knowing her whereabouts at all times and offering one-on-one activities when she appeared restless. Staff interviews consistently described her as frequently exit seeking, having numerous behaviors, and questioning instructions, but with no prior history of attempting to leave through a window. On the day of the incident, the resident was on COVID isolation in the memory care unit. A registered nurse reported having just returned the resident to her room, leaving the door open because the resident was a fall risk. Shortly thereafter, the Memory Care Director reopened the resident’s door after the resident had closed it, observing the resident seated in a chair with her lunch tray in front of her. Staff then proceeded to assist with passing lunch trays to other residents. Within approximately 10–15 minutes from the time the nurse placed the resident in her room, a resident assistant leaving the facility noticed that the screen was off one of the memory care windows and notified the receptionist and the Memory Care Director. When the Memory Care Director went to the resident’s room, she found the door closed, the window open, and the resident gone. Staff initiated a search inside and outside the building. The Memory Care Director reported seeing the resident’s bright pink sweater across a field near a roadway, along with a pickup truck and a police squad car. A receptionist stated that police called asking if the facility was missing a resident after a woman had been found near an auto parts store. The police report documented that a bystander had the resident in a pickup truck, that officers contacted the facility and confirmed the resident lived there, and that staff reported they had been searching for approximately 10 minutes. EMS documentation indicated the resident was found wandering near the roadway in a confused state, with advanced dementia, and had been moving on foot for an unknown period of time after eloping through a window. The Maintenance Director later stated that the window alarms on the unit were old, that the alarm on the window used by the resident had been knocked off, and that there had been no system in place to check the old alarms. The Director of Nursing confirmed there was no policy or plan regarding window alarms and no system for checking them, despite alarms being present to alert staff when windows were opened.
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