Failure to Supervise Cognitively Impaired Resident and Monitor Exit Doors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a cognitively impaired resident with a history of elopement. The resident, who had a BIMS score of 5 indicating severe cognitive impairment and required supervision with ambulation, was able to exit the facility through a locked dining room door without the door alarm sounding. The resident then accessed the patio/courtyard, exited through a gate, and did not return. Multiple staff members, including the DON, Assistant Administrator, and Activity Aides, reported not hearing any door alarms during the time the resident left, and surveillance footage confirmed the resident's exit without staff intervention or alarm activation. The resident had been admitted from an assisted living facility due to safety concerns related to wandering and medication management. Despite documentation of the resident's cognitive impairment and need for supervision, there was no evidence that staff had obtained a thorough history from the resident's family or the previous facility regarding elopement risk. Staff interviews revealed a lack of awareness of the resident's whereabouts, and there was no clear documentation of consistent monitoring or supervision, especially after the scheduled smoking time when the resident was last seen. The facility's policy required staff to know the whereabouts of assigned residents and to ensure that exit doors were secured and alarmed, but these procedures were not effectively implemented. The incident resulted in the resident being missing for an extended period, during which he was found wandering in another city and subsequently brought to a hospital. The failure to secure the exit doors, ensure alarm functionality, and provide adequate supervision for a resident with known cognitive impairment and elopement risk directly led to the deficiency. The facility's lack of effective communication, assessment, and monitoring contributed to the resident's unsupervised exit and subsequent absence.