Resident Elopement Due to Unsecured Exit and Inadequate Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with severe cognitive impairment. The resident, who had diagnoses including Parkinsonism, dementia, osteoarthritis, dystonia, dysphagia, psychosis, and major depressive disorder, was assessed with a BIMS score of 3, indicating severe cognitive impairment. Prior to the incident, the resident had no documented history of wandering or elopement risk, and the care plan did not include interventions for elopement prevention. On the day of the incident, the resident was able to exit the facility through an unlocked sliding door at the end of a hallway. This door was typically secured with a keypad lock, but on the day in question, it was found to be unlocked, and the alarm system was not functioning. The facility could not determine the exact cause of the malfunction but suspected it was related to weather conditions. The resident was found outside the facility by another resident and was returned to the building within approximately ten minutes of last being seen by staff. The incident was identified as non-compliance and Immediate Jeopardy, as the failure to secure the door and supervise the resident allowed the elopement to occur. The deficiency was based on direct observation, interviews, and record review, which confirmed that the resident was able to leave the facility unsupervised due to the malfunctioning door alarm and lack of adequate supervision.