Failure to Allow Cognitively Intact Resident Free Entry and Exit
Penalty
Summary
The facility failed to ensure that a cognitively intact resident, who was not at risk for elopement, could freely enter and exit the facility. The resident, who had diagnoses including osteonecrosis and alcohol dependence, was assessed as a low elopement risk and was independent with locomotion in his wheelchair. Despite this, the facility kept the entrance door locked at all times, requiring staff assistance to unlock it or waiting for an automatic release after 15 seconds, as observed during multiple site visits. The resident was seen waiting at the entrance for staff to unlock the door and expressed frustration about feeling confined and having to sign in and out like a prisoner. The facility's policy on a restraint-free environment states that residents have the right to be treated with respect and dignity and to be free from physical or chemical restraints used for staff convenience. The director of nursing confirmed that the door locking policy was implemented due to the admission of more residents who wander, but this policy also applied to residents who were not at risk for elopement. The lack of a system to allow cognitively intact, low-risk residents to move freely in and out of the facility resulted in a failure to honor the resident's rights to self-determination and dignity.