Failure to Maintain Secured Unit Doors and Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure that entrance and exit doors to the secured unit were functioning properly, resulting in the inability to safeguard residents and prevent elopement. Multiple observations and interviews revealed that a resident with a history of wandering and elopement risk was able to exit the facility on several occasions, including through a window and various doors. The resident was known to have delusional behaviors and was assessed as being at risk for elopement, with care plans and physician orders specifying the use of a wander guard and regular checks for its placement and function. However, documentation and staff interviews confirmed that the wander guard was not consistently in place, and there were periods when no replacement was available after it was lost. Facility records and staff statements indicated that exit doors and alarms were not consistently operational. Some doors did not alarm as intended, and in one instance, the alarm was so faint it could barely be heard. The front door, which was supposed to alarm when a wander guard was near, was reported to have malfunctioned, and the resident was able to exit. Additionally, a piece of paper with the gate code was posted next to an exit door, making it accessible to residents who could read, further compromising security. Maintenance staff acknowledged ongoing issues with door functionality and a lack of monitoring while repairs were pending. Staff interviews revealed that the resident had eloped multiple times, sometimes requiring law enforcement intervention to locate and return the resident. The resident was moved off the secured unit despite ongoing behavioral concerns and a history of elopement. Staff also reported that leadership was aware of the malfunctioning doors and alarms but did not implement effective interventions to prevent further incidents. There was no pertinent information in the facility's policy to support adequate prevention of elopement, and the administrator admitted that effective interventions were not in place to prevent the resident from leaving the facility.