Failure to Maintain Secured Unit Door Results in Resident Elopement
Penalty
Summary
The facility failed to maintain the door locking mechanism on an exterior door in the secured unit, which resulted in a resident with a known history of dementia, behavioral disturbances, and high elopement risk being able to exit the building unsupervised. The resident had a documented pattern of exit-seeking behaviors and had previously followed staff out of the secured unit on multiple occasions. Despite these behaviors and the resident's care plan indicating the use of a wander guard and the need for supervision, the door in question did not have a functioning wander guard locking mechanism and could be opened by pushing on it, as confirmed by staff interviews and direct observation. On the day of the incident, the resident was able to push open the door, which did not sound an alarm or prevent exit, and left the facility grounds. Staff members did not immediately realize the resident had left, and the resident was only discovered missing after being seen outside by a staff member returning from an appointment. The resident was ultimately found on a nearby highway, out of sight from the facility, and was returned by a staff member who located him in her car. Interviews with staff confirmed that the door's magnetic locking mechanism was loose and not functioning properly at the time of the incident. The resident involved had a history of psychiatric symptoms, including hallucinations, delusions, and agitation, and had been assessed as a high risk for elopement. Documentation showed repeated incidents of exit-seeking and confusion, with multiple notations in the medical record of the resident attempting to leave or expressing intent to do so. The failure to ensure the security of the door and to provide adequate supervision directly contributed to the resident's ability to elope from the secured unit.