Resident Elopement Due to Unsecured Exit During Patio Renovation
Penalty
Summary
The facility failed to maintain a safe environment for one resident who eloped from the premises through an unsecured exit gate. The resident, admitted with a diagnosis of bipolar schizoaffective disorder and assessed as having good memory and judgment, was outside on the basketball court patio with other residents when staff noticed the resident was missing. A search was conducted, but the resident was not found on the premises. Observations revealed that the basketball patio area had two exit doors with non-functioning security keypads, no working alarm speaker boxes, and both doors were unlocked and easily opened, leading directly to the parking lot. Staff confirmed that the area was under renovation and should not have been accessible to residents, and that the exit gates were not secured or alarmed as required. Facility policies reviewed indicated that all doors and locking mechanisms should always be working to prevent such incidents.