Failure to Prevent Elopement Due to Inadequate Supervision and Faulty Door Alarm
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was identified as being at risk for elopement. The resident, who had diagnoses including diabetes, high blood pressure, and dementia, was admitted with a care plan and physician's order for a secure care bracelet to monitor their location. Despite these interventions, the resident was able to exit the facility unsupervised and was found outside walking toward a main road by a hospice aide, who redirected the resident back inside. Staff statements indicated that the resident was last seen walking off the unit, and staff were occupied with other duties at the time. The resident was unable to recall how they exited the building or which door was used. Review of facility records and staff interviews revealed that the front door alarm system was not functioning appropriately at the time of the incident, with a significant delay in door closing. Other doors were functioning correctly, but the malfunction of the front door alarm contributed to the resident's ability to leave the facility undetected. The facility's policy required staff to be aware of the resident's location at all times, but this was not maintained, resulting in the resident being outside in cold weather without staff knowledge.