Failure to Secure Exit Doors Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that exit doors were secured and functioning properly, resulting in a resident with severe cognitive impairment and a known history of elopement being able to exit the building without staff knowledge. The resident, who had diagnoses including alcohol-induced persisting dementia, major depressive disorder, anxiety disorder, and altered mental status, was identified as an elopement risk and had a care plan reflecting this risk. Despite this, the resident was able to leave the facility through the front entrance door after a nurse had entered, and staff only became aware of the elopement when the resident was not found in their usual locations during rounds. Staff interviews and record reviews revealed that the front door's locking mechanism was unreliable, particularly during high winds, which could prevent the door from latching and cause alarms to malfunction. Maintenance staff and nursing personnel acknowledged that the issue with the door not latching due to wind was a known problem, and a note had been posted at the door to remind staff to ensure it was closed during high winds. Additionally, staff reported that the alarms at the front and side doors were not working at the time of the incident, and the door could be opened after a short delay even when it was supposed to be locked. The resident was eventually found by law enforcement in a field behind the facility and returned safely. The incident was documented, and staff interviews confirmed that the resident was more confused when off the secure unit. The facility's failure to maintain secure exit doors and ensure proper functioning of door alarms directly contributed to the resident's ability to elope, despite the resident's documented risk and history of similar behaviors.
Removal Plan
- Place resident in secured unit for safety and monitor by staff and nurse manager/designee.
- Re-inservice all staff on abuse prevention program and facility elopement policy.
- Assess all residents for elopement risk using elopement and wandering assessment, review care plans, and update care plans for residents at risk for elopement.
- Update elopement binder with resident pictures and demographics and inservice staff on use of elopement binder.
- Complete body audit, incident, accident and elopement form when resident is found and returned to building, including documentation of last seen, when resident was found, and notification of family and doctor.
- Recheck all doors by maintenance for working locking mechanisms.
- Contact door company to check all doors for proper working condition.