Failure to Respond to Door Alarm Results in Resident Elopement
Penalty
Summary
Staff failed to adequately respond to a door alarm, resulting in a resident with cognitive impairment and a history of wandering being found outside the facility without staff knowledge. The resident, diagnosed with metabolic encephalopathy and vascular dementia, was assessed as at risk for elopement and had a physician's order for a WanderGuard device, with checks required every shift. Despite these interventions, when the front door alarm sounded, staff assumed it was triggered by another resident standing by the door and turned off the alarm without checking outside, as required by facility procedure. The resident was later discovered at a house across the street. Review of facility records revealed that the magnetic lock on the front door was not consistently functioning due to a loose power wire, causing intermittent locking failures. Although the care plan and elopement assessment identified the resident's risk and interventions were in place, staff did not follow the established procedure to physically check outside when the alarm was activated. This lapse in supervision and failure to ensure the environment was free from accident hazards directly led to the resident's unsupervised exit from the facility.