Resident with Cognitive Impairment Found Unsupervised in Restricted Area via Elevator
Penalty
Summary
A deficiency occurred when a resident with significant cognitive and physical impairments, including hemiplegia, hemiparesis, impaired thought processes, and a history of wandering and exit-seeking behaviors, was found unsupervised in a restricted area of the facility. The resident, who required supervision or assistance to wheel 150 feet in a corridor, was discovered alone in a wheelchair on the elevator at the basement level, an area designated as unauthorized for residents and accessible only to staff. The basement exit doors were observed to be unlocked, unmanned, and lacking alarms or monitoring, further increasing the risk of unauthorized access. Staff interviews revealed that the elevator required a code to access restricted floors, but once the code was entered, the elevator could be used by residents without supervision, allowing them to reach unauthorized areas. There was no specific protocol in place for staff regarding elevator usage with residents, and staff education on this topic was limited to verbal instructions during orientation. The facility's policy on safety and supervision emphasized both facility-wide and individualized approaches to accident prevention, but did not address the specific risks associated with elevator access for residents with cognitive impairments. The incident was not previously identified or addressed through the facility's Quality Assurance and Performance Improvement (QAPI) process. Staff acknowledged that while such incidents were rare, there was no formal policy to prevent residents from accessing restricted areas via the elevator, and supervision relied on staff escorting residents back when found. The lack of adequate supervision and security measures in this instance resulted in a resident with known risks being able to access an unauthorized and potentially hazardous area without staff awareness.