Failure to Secure Front Entrance Results in Resident Elopement and Injury
Penalty
Summary
The facility failed to ensure that the front entrance was safely supervised and/or secured, resulting in a resident with severe cognitive impairment and multiple medical conditions exiting the building without staff knowledge. The resident, who was at high risk for falls and had a care plan indicating the need for a safe environment and supervision, was last seen in bed by a CNA during the night shift. Staff discovered the resident missing approximately 45 minutes later and began searching the facility, initially believing that door alarms would have sounded if the resident had exited. Upon checking, staff found that the front door alarm was not activated or not functioning, and the alarm did not sound when tested. The resident was eventually found by police across a four-lane highway, wearing only a hospital gown, a brief, and shoes, in cold weather conditions. The resident was confused, had sustained injuries including a missing tooth and abrasions, and was hypothermic with a body temperature of 93.2°F. Emergency department records confirmed an acute subdural hematoma, hypothermia due to cold environment, and an unwitnessed fall. The resident was admitted to the hospital for further care. Interviews with staff and review of video footage confirmed that the resident exited through the front door during the early morning hours, and that the door alarm system was not functioning as required. The facility's elopement policy required adequate supervision and a safe environment for all residents, but these measures were not effectively implemented, allowing the resident to leave the facility undetected.
Removal Plan
- Conducted a full house audit of all residents to identify those who are an elopement risk.
- Conducted in-services with all staff on the elopement policy.
- Evaluated and inspected the front door alarm system and found it to be in good working condition.
- Installed a lock box over the kill switch located in the ceiling, with access limited to supervisory/authorized staff.
- Installed a new code panel on the internal set of glass doors requiring a code to exit the facility.
- Checked all other exit doors and found them to be fully engaged and functioning.
- Checked all bed/chair/personal alarms and found them to be in good working condition.
- Checked doors equipped with the Wander Guard system and found them to be properly functioning.
- Initiated a QA audit tool for maintenance to check the alarmed doors and wander guard equipped doors for proper functioning.
- In-serviced all staff on the importance of immediately responding to exit door alarms.
- In-serviced all staff on ensuring that the front exit door alarm is consistently activated.
- Initiated a QA audit tool to ensure that the front alarm door is properly functioning.
- Held an emergency QAPI meeting attended by the Medical Director to develop and approve the plan of correction.
- Agreed to discuss all trends identified in the monthly QAPI meeting until resolution.