Failure to Repair Door Alarms Leads to Resident Elopement
Penalty
Summary
The facility failed to identify and eliminate known and foreseeable accident hazards in the environment, specifically by not repairing malfunctioning door alarms for several years. Three exit doors, including the one used during the incident, were not functioning with the wander guard alarm system, and one of these doors also lacked a working contact (noise) alarm. The facility was aware of these issues, as confirmed by interviews with the maintenance director and DON, but repairs were not completed, and there was no clear documentation or follow-up on previous repair proposals. The malfunctioning doors provided access to the outside of the building, and the lack of effective alarms meant that staff were not alerted when a resident exited the facility. A male resident with Alzheimer's disease, a history of stroke, dysphasia, heart failure, a pacemaker, and lack of coordination was admitted with significant cognitive impairment, as indicated by a BIMS score too low to complete the assessment. His care plan included interventions for risk of elopement, such as ensuring the wander guard was working, and he had an order for staff to monitor the wander guard device every shift. Despite these interventions, the resident was able to exit the facility through a basement egress door without triggering an alarm. Video surveillance showed the resident leaving the building, crossing parking lots, and walking along a busy street before being returned by a staff member who saw him outside. The facility was unaware of his absence until he was seen by staff outside the building. Staff interviews revealed that the wander guard system had not been working on three doors for years, and the contact alarm on the door used during the elopement was also broken at the time of the incident. The maintenance director was responsible for weekly checks but was unsure why repairs had not been completed. The administrator was unaware that the door was not working, and there was no policy for continuous camera monitoring. Staff also reported that frequent alarms from other doors had become background noise, leading to alarms being ignored. The facility's policies required identification and mitigation of hazards, including malfunctioning equipment and disabled alarms, but these were not followed, resulting in the resident's elopement.