Failure to Monitor Exit Doors and Alarm Systems Resulting in Resident Elopement
Penalty
Summary
A resident with a diagnosis of dementia, identified as an elopement risk and equipped with a wander guard alert device, was able to exit the facility unnoticed. The resident left through an unlocked and non-alarmed door, and the wander guard did not activate an alarm or lock the door as intended. The resident was outside for approximately thirty-three minutes before being found by staff, after a visitor alerted them to the resident's presence outside in a wheelchair near the gazebo across the employee parking lot. Facility records and video surveillance confirmed that the resident exited through the D Wing door without staff awareness. Interviews with staff, including an LPN and the DON, corroborated that the alarm system failed to function and that the door was not secured. The resident was assessed after being returned to the facility and was found to have no lasting effects from the incident. The deficiency resulted from the lack of monitoring and failure of safety devices intended to prevent elopement for residents at risk.