Failure to Prevent Resident Elopement Due to Staff Sharing Door Codes
Penalty
Summary
A deficiency occurred when a resident was able to exit the facility without staff knowledge by using a code to the entrance/exit doors that had been provided by facility staff. The resident, who had a diagnosis of non-Alzheimer's dementia and was considered cognitively intact with a BIMS score of 15, was found outside the building by a CNA after being unsupervised for approximately 5-10 minutes. The resident reported that the code to the door was given by a CNA, and further interviews revealed that multiple residents knew the codes to various exit doors, which were also provided by staff. Observations and interviews indicated that several residents, including those who smoked, routinely used the door codes to exit and re-enter the building without staff supervision. Staff members confirmed that residents had been seen using the codes to access outdoor areas, and some residents stated that all residents who smoked or wanted to go outside had the code. It was also noted that the alarm on the door used by the resident did not function, and that staff were not always aware when residents exited the building. The facility had multiple exit doors, some of which led to areas with potential hazards such as cleaning equipment and concrete surfaces. Staff interviews confirmed that residents were able to obtain the codes from aides or nurses, and that supervision was not consistently provided when residents exited. The care plan for the resident involved indicated a history of wandering and attempts to hoard smoking materials, and the resident's family had previously requested placement on a secure unit. Despite these factors, the resident was able to exit the facility unsupervised due to staff providing door codes and lack of effective monitoring.