Failure to Secure Exit Door Results in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, cognitive impairment, and a history of wandering exited the facility through a side service hall exit door that was not properly secured. The resident was independently ambulatory, had demonstrated exit-seeking behaviors, and was assessed as being at significant risk for elopement. The care plan included the use of a wanderguard and regular checks of its function, and physician orders specified placement of the wanderguard and monitoring each shift. Despite these interventions, the resident was able to leave the building undetected and was only noticed by a dietary employee outside, after which the resident was promptly escorted back inside. Investigation revealed that the service hall exit door was not armed with wanderguard locking devices but was equipped with an alarm system that should have sounded when the door was opened. However, staff did not hear the alarm at the time of the incident. Subsequent testing by facility staff showed that the alarm did not sound when the door was opened, and it was unclear why the alarm had been disarmed. There was also confusion among staff regarding the door's locking mechanism, specifically about a delay in the door rearming after being closed, which was not widely understood by staff members. Documentation and interviews indicated that the event was not immediately or thoroughly documented in the resident's progress notes, with no immediate intervention or physical assessment recorded following the elopement. Staff in-service records showed that not all employees had received training on the elopement policy or the secured door system at the time of the incident. Manufacturer guidelines for the door's alarm system were reviewed, highlighting the potential for a rearm delay, but staff were generally unaware of this feature. The facility's policy required immediate assistance and documentation when a resident elopes, which was not fully followed in this case.