Resident Elopement Due to Faulty Door Alarm and Inadequate Supervision
Penalty
Summary
A resident with diagnoses of dementia, depression, Alzheimer's disease, and stage 3 chronic kidney disease eloped from the facility through an unsecured and improperly alarmed exit door. The resident was able to exit the south exit door without staff observation, and the door alarm, which was intended to sound continuously until reset by staff, ceased once the door closed. This malfunction allowed the resident to leave the premises undetected by staff. The resident was not immediately noticed missing by staff; instead, another resident witnessed the elopement and alerted a CNA, who then informed an LPN to initiate a search. The resident was found and returned to the facility by a former employee approximately 20 minutes later, after having traveled about one third of a mile on foot. Upon return, a full physical and psychosocial assessment was conducted, and no concerns were noted. The facility's investigation determined that the root cause of the incident was the disengagement of the door/alarm system, which allowed the alarm to reset improperly. Staff interviews confirmed that the alarm system was old and not functioning as intended, and that staff were unaware of the resident's exit until notified by another resident. The resident was identified as an elopement risk with impaired safety awareness, and the care plan included monitoring and diversional interventions, but these were not sufficient to prevent the incident.