Failure to Prevent Resident Elopement Due to Inoperative Door Alarm
Penalty
Summary
A resident with a history of dementia, disorientation, and a recent fracture was admitted to the facility and assessed as a moderate elopement risk upon admission. The resident's cognitive status declined over time, as indicated by a drop in the BIMS score from 10 to 3, reflecting severe cognitive impairment. Physician orders were in place for a wanderguard device due to the risk of elopement, and staff were instructed to monitor the device's function. Despite these measures, the resident was last seen at the nurses station and was later found at a nearby emergency room, having left the facility without staff knowledge. Staff interviews confirmed that the wanderguard was in place at the time of the incident, but the front door alarm was not functioning, allowing the resident to exit undetected. Staff reported that residents at risk for elopement are typically monitored with wanderguards and that door alarms are expected to alert staff if such residents approach exits. However, on the day of the incident, the malfunctioning front door alarm failed to activate, and the resident was able to leave the premises. The deficiency was further evidenced by staff statements acknowledging the resident's increased elopement risk following improved mobility and the lack of immediate staff awareness of the resident's departure. Facility policy required reinforcement of procedures for residents at risk of elopement, but these procedures were not effectively implemented in this case.