Failure to Properly Respond to Door Alarm Allows Resident Exit
Penalty
Summary
A resident with severe cognitive impairment and a history of elopement risk exited the care center through alarmed double doors without proper staff intervention. The resident required partial to moderate assistance for mobility and transfers, and his care plan included specific interventions such as door security systems, closed double doors, and frequent checks. On the day of the incident, the resident left the unit through the double doors, which triggered the alarm. A staff member, upon hearing the alarm, looked down the hall, saw a male resident heading toward the Bistro, and mistakenly assumed it was another resident who would be signed out by independent living. The staff member turned off the alarm without verifying the identity of the individual or notifying nursing staff as required by protocol. The resident was later found outside the care center double doors, attempting to locate his room, and was returned to his room without injury. The facility's policy required staff to respond to door alarms by identifying the cause and notifying the charge nurse if the cause was unknown. The staff member involved admitted to not being certain of the resident's identity and acknowledged that he should have checked on the resident and been more proactive. The administrator confirmed that the staff member did not follow protocol by failing to verify who set off the alarm.