Failure to Prevent Elopement Due to Inadequate Supervision and Faulty Exit Door Alarm
Penalty
Summary
The facility failed to maintain a safe and secure environment for two residents who were at risk for elopement. Both residents had documented histories and care plans indicating their risk for elopement, with one resident being independent in decision-making and the other unable to make medical decisions but able to express needs. Despite these risks, both residents were able to leave the premises through an exit door in the smoking area. The incident occurred when the residents were observed in the courtyard, and one resident kicked the exit door, allowing both to exit the facility. Staff only became aware of the elopement after hearing the banging of the door, and no alarm was heard at the time, even though the door was supposed to be alarmed. Interviews and video evidence confirmed that no staff were present by the exit door at the time of the incident, and the alarm system did not function as intended. The Maintenance Director stated that exit doors were checked daily but admitted there was no maintenance log to document these checks. The lack of staff supervision in the area and the failure of the alarm system contributed to the residents' ability to elope, placing them at risk for harm or injury.