Failure to Prevent Elopement Due to Unsecured Therapy Room Door
Penalty
Summary
A deficiency occurred when a resident, identified as being at risk for elopement due to diagnoses including dementia, tremor, dizziness, and hypertension, was found outside the facility by the physical therapy office back door. The resident's clinical record indicated a BIMS score of 99, signifying an inability to complete the mental status interview, and a care plan specifically identified the resident as an elopement risk with a goal to maintain safety. On the day of the incident, the resident was discovered outside by an activities team member at approximately 5:00 p.m. Interviews with facility staff revealed that the physical therapy office back door was not equipped with an alarm, and the door had been left unlocked by someone from the physical therapy department. The Assistant Director of Nursing and the Administrator both confirmed that the resident was not supposed to be in the therapy rooms unattended and that it was expected for these doors to be locked when not in use. The facility's policy emphasized the resident's right to a safe environment, but the lack of adequate supervision and failure to secure the therapy room door led to the resident's unsupervised exit.