Failure to Prevent Resident Elopement Due to Disabled Door Alarm and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including schizoaffective disorder and muscle weakness, was able to leave the facility unsupervised. The resident exited through a side door whose alarm had been turned off, and staff were unaware of her absence until notified by another resident who was outside. The resident was found walking with her walker on the sidewalk approximately 400 feet from the facility, heading toward a nearby restaurant. At the time of the incident, the resident's care plan did not include interventions for wandering or exit-seeking, and her most recent elopement risk assessment indicated she was not at risk for elopement. The facility's failure to provide adequate supervision and maintain functional door alarms directly contributed to the resident's elopement. The double doors by the dining room, which the resident used to exit, were found to have their alarm system turned off. Maintenance staff later confirmed that the alarm could be disabled with a key, and that multiple staff members had access to these keys. The facility's policy required the use of door alarms or monitoring devices to notify staff when residents attempt to leave, but this was not followed in this instance. Interviews with staff and review of records confirmed that the resident was not identified as an elopement risk prior to the incident, and there were no care plan interventions addressing wandering or exit-seeking behaviors. The lack of appropriate risk assessment, supervision, and environmental safeguards led to the resident leaving the facility without staff knowledge, resulting in a deficiency related to accident prevention and resident safety.