Failure to Prevent Unsupervised Exit of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment exited the facility unsupervised through the front door, which was held open by a lawn service worker. The resident, who had a BIMS score of 7 indicating severe cognitive impairment and diagnoses including heart failure and vascular dementia, was not identified as an elopement risk and had no prior history of wandering behaviors. Despite this, the resident was able to leave the building in her wheelchair without staff noticing. The incident took place when a lawn care worker, who did not speak or read English, opened and held the facility's front door while waiting to exit after completing work in the inner courtyard. The worker was unable to interpret the posted signage instructing individuals not to allow residents to exit. As a result, the resident followed the worker outside and was left unsupervised in the facility's parking lot for approximately three minutes before being found by a visitor. Staff interviews and record reviews confirmed that the resident was last seen inside the facility at 11:05 AM and was found at 11:08 AM, approximately 145 feet from the front door. The resident was assessed and found to be in no distress, and all other residents were accounted for following the incident. The facility's policy required the environment to be as free from accident hazards as possible and for residents to receive adequate supervision to prevent accidents, but these measures were not effectively implemented in this case.