Failure to Identify and Address Unalarmed Exit Doors Leading to Resident Elopement
Penalty
Summary
The facility failed to conduct a thorough investigation after a resident exited the building through doors that were not equipped with a wander guard alarm system. The resident was able to leave the property, access a public road, and travel 0.2 miles on foot without staff supervision. The facility's report indicated that while the emergency egress door at the end of the hall was alarmed and staff responded to the alarm, they did not see any residents outside and subsequently contacted local law enforcement. The resident was later found and returned to the facility by police. The investigation did not address the fact that the first set of exit doors, which the resident used to leave, were not equipped with a wander guard alarm system, allowing the resident to reach the emergency egress doors and exit the facility. Interviews revealed that the interdisciplinary team (IDT) reviewed the incident, but the lack of a progress note summary in the resident's medical record was noted. Staff confirmed that certain doors in the facility, including those on the sapphire and crossroads units, were not alarmed with a wander guard system and that this was not identified as the root cause of the elopement. The rationale provided was that the second set of doors, which were emergency egress doors, were alarmed and would alert staff if a resident exited. However, the absence of alarms on the first set of doors was not addressed as a contributing factor to the resident's ability to elope.