Resident with Cognitive Impairment Accesses Locked Door, Falls Down Stairs
Penalty
Summary
A resident with severe cognitive impairment, dementia, and a history of wandering and elopement risk was not adequately protected from accident hazards within the facility. The resident's care plan identified risks for elopement and falls, directing staff to provide supervision, diversions, and structured activities to prevent wandering. Despite these interventions, the resident was last seen in the dining room with staff before going missing. Staff initiated a search, including looking outside, and eventually found the resident at the bottom of a basement staircase, having accessed a key code locked door with his wheelchair and fallen down the stairs. The incident report documented that the resident sustained a hematoma to the face and right forearm, as well as an abrasion and bruise to the left hand, requiring evaluation at the emergency room. Staff interviews revealed that the resident may have figured out the code to the basement door, which was supposed to be locked. Observations showed that the door had a key code lock with a deadbolt latch that, if turned, would allow the door to open without entering the code, although the keys would still light up as if the code was being entered. Staff were generally unaware that the door could be accessed in this manner, and some were not even aware of the basement's existence. The maintenance staff confirmed that the door and lock were functioning as intended upon inspection, and that the door was supposed to lock automatically. However, the incident demonstrated that the resident was able to access the basement, leading to a fall and injury. The facility census at the time was 29 residents, and the event highlighted a failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents for this resident.