Failure to Prevent Resident Elopement Through Unmonitored Front Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent a resident from exiting the facility without staff knowledge. The resident was admitted with Wernicke’s encephalopathy and was described in various assessments as alert and oriented to name and place, sometimes to time, but also forgetful, confused at times, and unhappy or not accepting of placement. An elopement and wandering risk assessment documented that the resident was alert and oriented x3 and able to follow instructions, while also expressing dissatisfaction with being in the facility. Nursing notes indicated the resident was ambulatory with a cane and moved between his room, the lobby, activity room, and patio. On the day of the incident, staff documented that the resident was in his room at approximately 3:15 p.m., later seen in the lobby doing word search puzzles, and received medications in the lobby around 4:00 p.m. The resident ate dinner in his room between about 4:30 and 5:00 p.m., and was again seen at the front nurse station asking for a pen and sitting in the lobby. The charge nurse reported noticing during rounds between 6:00 and 6:30 p.m. that the resident was not in his room, and staff initiated the facility’s missing resident code and searched the building and surrounding area without locating him. A CNA reported last seeing the resident around 5:50 p.m. when picking up the dinner tray and stated he did not check further on the resident because he considered the resident independent. Review of surveillance footage with maintenance staff showed the resident, dressed in regular clothes, exiting through the front door at 6:59 p.m. It was noted that the front door did not have an alarm at that time and was routinely locked at 8:00 p.m. Interviews with nursing staff and the DON revealed that after the receptionist leaves, there is no specific person assigned to monitor the front door; instead, LVNs, the desk nurse, charge nurse, RN, or a CNA at Station 1 are expected to keep an eye on it. Staff acknowledged that although there should always be someone at Station 1, this was not guaranteed, especially during busy hours between 6:00 and 9:00 p.m. The resident was later reported by a GACH RN to have been found by law enforcement wandering on a college campus and transported to the hospital. The facility’s policy stated that the environment should be as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents are facility-wide priorities.
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