Resident Elopement Due to Delayed Staff Response to Security Alarm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known history of elopement risk exited the facility without staff knowledge. The resident was last seen ambulating in a hallway and was later found approximately 350 feet away in a nearby fast-food restaurant parking lot. The facility had an electronic security bracelet system in place for the resident, which was functioning at the time, and a door alarm was activated. However, staff response to the alarm was delayed, with the responding LVN arriving at the door within five minutes, searching the area, but failing to locate the resident. The resident was ultimately found and returned to the facility by staff after being identified by a former employee outside the premises. The resident's records indicated a history of impaired cognition and previous elopement risk, with interventions in place such as a security bracelet. Despite these measures, the staff did not respond to the door alarm within the facility's expected timeframe of one minute or less, and the initial search did not result in locating the resident. The facility's policy defined elopement as a resident exiting without staff knowledge, which occurred in this incident. No injuries were noted upon the resident's return, but the event demonstrated a failure to provide adequate supervision and prevent accidents as required.