Failure to Maintain Functioning Elopement Alarm System
Penalty
Summary
The facility failed to ensure the proper functioning of the electronic monitoring alarm control panel, which is crucial for the safety of residents at high risk for elopement. This deficiency was identified during an observation on April 1, 2025, when a resident with an electronic monitoring device on his ankle approached the main exit door, and the alarm did not activate. The alarm control panel was found to be without power, and the Maintenance Director confirmed that the transformer was not working and needed replacement. Four residents, all identified as high risk for elopement, were affected by this deficiency. These residents had various diagnoses, including dementia and cognitive impairments, and were equipped with electronic monitoring devices as per physician orders. The facility's guidelines require that these devices and the exit door alarms be checked daily for functionality, but the failure of the alarm system indicates a lapse in this protocol. The deficiency was observed in the context of the facility's elopement and search guidelines, which mandate the use of elopement prevention devices for residents assessed as high risk. Despite these guidelines, the malfunctioning alarm system compromised the safety measures intended to prevent elopement, as evidenced by the non-functioning alarm when tested with a resident at risk.