Failure to Supervise High-Risk Resident and Respond to Exit Door Alarms
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident with a known history of elopement. The resident had dementia, depression, Wernicke’s encephalopathy, heart failure, hypertension, and diabetes, and used a wheelchair for mobility. An Elopement Risk Evaluation identified the resident as an imminent elopement risk, with a prior elopement and a care plan that included a wanderguard, close supervision, and regular compliance rounds. Despite this, the resident was able to leave the building unnoticed and was later observed outside across the street from the facility. On the day of the incident, staffing records showed only one nurse and one Certified Medication Technician assigned to the second floor day shift, with no other staff scheduled on that floor. The resident’s assigned CNA last saw the resident asleep in his/her room early in the morning and was aware the resident had eloped previously but did not know when. The nurse’s note documented that the resident eloped and was escorted back into the facility, but did not specify how the resident exited the building. The resident later stated he/she did not remember leaving but expressed a desire to go outside at times. Environmental observations and staff interviews revealed that the second floor had two exit doors that were alarmed but did not have wanderguard sensors, and the front door was the only door equipped with a wanderguard sensor. Testing of the second floor exit doors showed one alarm near a resident room sounded for only about three seconds before stopping while the door remained open, and another exit alarm in the dining room sounded for about 30 seconds, yet no staff responded to either alarm. Staff on the second floor, including therapy staff and housekeeping, either did not hear the alarms or heard them but did not investigate. The Maintenance Director was unaware of the malfunctioning alarm, and the Administrator stated there should always be at least one staff member on the second floor and that staff were expected to respond immediately to door alarms, but this did not occur on the day of the elopement.
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