Failure to Maintain Safe Environment for Resident at Risk of Wandering
Penalty
Summary
The facility failed to ensure a safe environment for a resident, who was at risk for wandering and falls. The resident, diagnosed with Alzheimer's dementia, was assessed as being at moderate risk for wandering. Despite this, the resident was able to exit the facility undetected due to a series of failures in the safety measures that were supposed to be in place. The care plan for the resident included the use of a door alarm to alert staff if the resident left her room, but this alarm was not activated by the LPN responsible for the resident's care. Additionally, the facility's preventative maintenance log showed a lack of documentation for the monthly checks and replacement of door alarm batteries. This oversight contributed to the failure of the door alarms, as the batteries were found to be dead, allowing the resident to exit the facility without triggering an alarm. The resident was later found outside near the smoke shed, indicating a significant lapse in the facility's safety protocols. Interviews with the Director of Nursing confirmed that the door alarm on the resident's room was not turned on as required, and the door leading to the chapel and the exit door did not function properly due to dead batteries. This series of inactions and failures in following established safety protocols led to the resident being able to leave the facility undetected, highlighting a critical deficiency in maintaining a safe environment for residents at risk of wandering.