Failure to Prevent Elopement of Two Cognitively Impaired Wanderers
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for two residents with known wandering and elopement risk. Both residents were ambulatory, frequently walked throughout the facility together, and were known to staff as wanderers. Each resident had a diagnosis of dementia with severe cognitive deficits documented on their MDS assessments, and both had Wander/elopement alarms (wander guard bracelets) in place and used daily. The facility’s elopement/wandering policy stated that residents who are incapable of adequately protecting themselves and unable to determine when they are at risk for harm by wandering out of the facility should be placed on the resident security system to ensure safety. On the day of the incident, video surveillance later reviewed by the Administrator showed that a visitor entered an exit door on the B Unit at approximately 6:20 PM. The two residents at risk for elopement approached the door, and the visitor held the door open, allowing them to walk out of the building. The residents were wearing wander guard bracelets, and when they exited, the door alarm sounded. A nurse responded immediately to the alarm, exited the facility, and went down the walkway but did not see the residents. Staff were then alerted that the residents were missing, and a facility-wide search was initiated. Staff interviews and the facility’s documentation confirmed that the residents had previously been observed walking together throughout the facility and approaching doors, including the exit door involved in the incident. The Administrator reported that review of the video showed the two residents had approached the same door together two or three times prior to the elopement event. Despite their known patterns of wandering, severe cognitive impairment, and prior door-approach behavior, the residents were able to exit the facility unnoticed and unsupervised when the visitor held the door open. Staff ultimately located the residents across a four-lane high-capacity highway approximately 528 feet from the exit door and returned them to the facility, where body audits and assessments documented no injuries and intermittent confusion. The State Agency determined that the facility’s failure to provide adequate supervision to prevent the elopement of these residents, who had exhibited exit-seeking behaviors, placed them and other residents at risk for wandering and elopement in a situation likely to cause serious injury, harm, impairment, or death and cited the facility at F689 with Immediate Jeopardy and Substandard Quality of Care. The residents’ medical records and elopement reports documented that both were confused, had impaired memory, and were identified as wanderers. One resident had a BIMS score of 3 and the other a BIMS score of 0, both indicating severe cognitive deficits. Progress notes and elopement reports recorded that staff were notified when the residents were not on the unit and could not be located, that all staff were engaged in searching, and that the residents were ultimately found outside and assisted back into the building. Interviews with CNAs and an LPN described hearing a Code W called, running outside, and seeing the residents across the street after they had crossed the four-lane highway. The DON acknowledged that the residents were always walking in the facility, often together, and that they had wandered to doors and looked out, and agreed that increased monitoring and not allowing visitors to have door codes could have prevented the residents from leaving the building.
Removal Plan
- Conducted a facility search.
- Notified police of missing residents.
- Director of Nursing interviewed staff and residents.
- Notified the Medical Director and residents’ families.
- Administrator and Director of Nursing checked the wander guard system and facility doors to ensure proper functioning.
- Returned Resident #1 and Resident #2 to the facility.
- Completed an incident report.
- Completed an emergency Quality Assurance meeting.
- Initiated in-service training for all staff on the elopement policy, including a quiz to validate comprehension, and required staff (including contract staff) to complete the in-service before working their next scheduled shift, with Administrator monitoring compliance.
- Responded immediately to the door alarm by sending staff outside to locate residents and notifying additional staff to assist with the search.
- Reviewed video surveillance and confirmed a visitor held the door open allowing residents to exit.
- Held an emergency Quality Assurance meeting with the Medical Director, Director of Nursing, Administrator, Regional Director, involved staff, and Infection Preventionist.
- Changed the main entry door code.
- Verified entrance door signage was in place instructing not to allow residents to exit unaccompanied.
- Identified residents at risk for elopement and ensured elopement bracelets/transmitters were functional and doors were locking appropriately.
- Reviewed care plans for residents at risk for elopement.
- Completed body audits on Resident #1 and Resident #2.
- Conducted audits verifying resident location, elopement risk, and wander guard bracelet function.
- Medical Records updated care profiles of residents at risk for wandering.
- Assistant Administrator began audits of all doors for function and security.
- Provided in-services on elopement policy and procedure, Resident Rights, and incident and accident reporting.
- Conducted elopement drills on each shift.
- Implemented monitoring systems to sustain compliance.
- Director of Nursing to monitor wander guard system checks three times weekly for four weeks or until substantial compliance is attained.
- Director of Nursing to monitor resident behavior for elopement attempts via incident reports, observations, and communications weekly for four weeks or until substantial compliance is attained.
- Quality Assurance Committee to meet for four weeks to review compliance with the plan of action, then continue routine Quality Assurance monitoring if no further concerns are noted.
- Administrator to hold follow-up Quality Assurance meetings monthly for two months then quarterly thereafter to ensure sustained compliance.
- Updated entry screening kiosk to include an additional reminder and attestation to ensure resident safety, requiring visitors to agree that no resident comes in or out with them and triggering a staff alert if the visitor refuses.
- Administration spoke directly with the visitor to confirm visitor policies and procedures.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.