Failure to Secure Front Entrance Resulting in Unsupervised Resident Exit
Penalty
Summary
A deficiency occurred when a resident with diagnoses of dementia, depression, and convulsions, who had a physician's order to leave the facility only with a responsible party and required supervision for transfers and ambulation, was able to exit the facility unattended. The resident was last seen in the dining room and was later found off facility grounds in a nearby parking lot. The resident was able to ambulate independently but required assistance due to fall risk and impaired cognition, as documented in the care plan and confirmed by therapy staff. The investigation revealed that the front entrance door, which was supposed to be locked when the receptionist was not present, was found unlocked on the morning of the incident. Staff interviews indicated that the door was sometimes left unlocked for convenience, allowing staff and housekeepers to enter, and that there was not always someone monitoring the front desk. The receptionist, who arrived after the resident had already left, confirmed the door was unlocked upon arrival and had seen someone matching the resident's description walking outside. Facility policy required that residents not be unsupervised outside the facility, and staff were expected to monitor the front entrance. However, inconsistent practices regarding the locking and monitoring of the front door allowed the resident to leave the building without staff knowledge or supervision, contrary to the resident's care plan and physician's orders.