Failure to Prevent Elopement Due to Inadequate Supervision and Faulty Door Alarm
Penalty
Summary
A resident with dementia and insomnia, identified as being at risk for elopement and having impaired cognition, was able to exit the facility unsupervised through a dining room door. The door alarm, which was intended to alert staff to unauthorized exits, was not functioning properly at the time of the incident. Staff became aware of the resident's absence only after a neighbor notified them that the resident was walking down the street. The resident was subsequently retrieved by staff and brought back to the facility. Review of facility records indicated that the door alarm had last been checked several days prior to the incident, and maintenance staff were unaware of the malfunction. The area where the resident exited was only partially fenced and the door did not have a lock. Staff interviews confirmed that the resident was known to be an elopement risk and that supervision was momentarily interrupted during a shift change, which coincided with the resident's exit. The facility's policy requires adequate supervision and functioning safety measures for residents at risk of wandering or elopement, which were not in place at the time of the event.