Resident Elopement Due to Delayed Door Alarm and Unnoticed Exit
Penalty
Summary
A resident with moderate cognitive impairment, as indicated by a BIMS score of 9 and diagnoses including Wernicke's encephalopathy and cognitive communication deficit, was able to exit the facility unsupervised. The resident was last seen by staff visiting another resident and was later observed outside the facility by a staff member driving by, who then notified facility staff. The resident stated that someone held the door open for her, and the facility determined that she likely followed an employee out of the locked unit. At the time of the incident, the door alarm system had a 10-second delay before sounding, and the alarm did not activate during the event. The resident had no prior history of exit-seeking behaviors and was independent in mobility and activities of daily living. The facility's daily door checks had not previously identified any issues with the alarm system, and staff were unaware that the resident had exited until notified by the staff member outside. The resident was found outside in appropriate clothing for the weather and was assessed to have no injuries upon return. The facility's investigation concluded that staff acted according to existing policy, and the elopement was not preceded by any behavioral changes or warning signs from the resident.