Elopement Due to Unsecured Window and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease and a psychotic disorder, who had a documented history of elopement and was admitted specifically due to increased elopement risk, was able to exit the facility unsupervised. The resident's baseline care plan indicated a risk for wandering or attempting to leave the facility unattended. On the day of the incident, the resident exited through her bedroom window into the facility's enclosed courtyard without staff awareness, as there was no alarm to notify staff of her exit. Prior to the incident, a Certified Nursing Assistant (CNA) observed that the resident's window was open and the screen was damaged. The CNA reported the hole in the window screen to the Maintenance Assistant but did not communicate that the window itself was unsecured or fully open. The Maintenance Assistant did not assess the reported damage before the incident occurred. As a result, the window remained unsecured, providing an opportunity for the resident to exit the building. The resident was last seen inside the facility around 6:00 pm and was found in the courtyard at 6:15 pm after a neighbor notified staff. A Code Yellow was initiated, and the resident was located and returned inside without injury or distress. The lack of timely and thorough reporting, assessment, and repair of the window and screen, as well as insufficient supervision, directly contributed to the resident's ability to elope from the secured unit.