Failure to Secure Exit Door for Residents at Risk of Elopement
Penalty
Summary
The facility failed to ensure that exit doors were properly secured to prevent residents at risk for elopement from exiting the building unassisted. Observations revealed that door #5, located in an area not visible from nursing stations or busy areas, was accessible to residents and could be opened to the outside without triggering an alarm. The door was equipped with both a keypad and a wanderguard system, but neither functioned as intended. The keypad had been nonfunctional for over a week, and the wanderguard system did not lock or alarm when tested with a bracelet identical to those worn by at-risk residents. Maintenance staff confirmed the door's inconsistent locking and lack of alarm, and that the door led directly to an unsecured parking lot and a busy highway. No staff were present to monitor the door during these observations. Record review and interviews confirmed that at least ten residents, including one with severe cognitive impairment and a history of wandering and elopement risk, resided outside the secured unit and had access to the unsecured door. The care plan for this resident included the use of a wanderguard device, and staff reported that the resident frequently attempted to open exit doors. The facility's policy required that residents at risk for elopement receive adequate supervision and that door alarms and locks be maintained to prevent accidents. Despite this, the malfunctioning door and lack of staff monitoring created a situation where residents at risk for elopement could have exited the facility undetected.