Failure to Timely Investigate Resident Elopement After Alarm Ignored
Penalty
Summary
The facility failed to initiate a timely investigation after a resident with a history of hallucinations and dementia exited the facility unsupervised. The resident was last seen inside the facility at approximately 4:00 AM and was found by dietary staff in the facility parking lot around 4:30 AM. Staff were unaware that the resident had left the building, despite an audible alarm sounding on an exit door, which was not investigated by staff at the time. Interviews revealed that the LPN on duty heard the alarm but did not investigate, and other staff members also failed to respond to the alarm. The resident was discovered outside by a dietary employee arriving for work, who then notified nursing staff. The resident reported leaving the facility due to feeling threatened by a nurse. The LPN and other staff brought the resident back inside but did not conduct an immediate investigation or interview the dietary staff who found the resident. The Administrator was notified of the alarm and the resident's exit but was not made aware of the full circumstances, including that the resident had been found outside by non-nursing staff, until several days later. The Director of Nursing was also not informed of the elopement until the State Agency arrived. As a result, the facility did not begin an internal investigation into the incident until two days after the event, delaying the identification of root causes such as staff failure to respond to alarms and lack of awareness of the resident's whereabouts.