Resident Elopement Due to Inaudible Door Alarm and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of Alzheimer's disease, psychotic disorder, and Parkinson's disease, who was assessed as being at risk for elopement due to wandering behaviors and cognitive impairment, exited the facility through an alarmed door without staff knowledge. The resident was independently mobile with a walker and required supervision for activities of daily living. The care plan identified the risk for elopement and included interventions such as redirection and structured activities, but these were not sufficient to prevent the incident. On the day of the event, two aides were present on the unit and were unaware of the resident's elopement risk. The door alarm, which was intended to alert staff to unauthorized exits, was not loud enough to be heard from the nurses' station where the aides were located. The aides only became aware of the resident's exit after being notified by staff from another unit, who had been contacted by the police upon finding the resident outside. Facility staff interviews and observations confirmed that the alarm was not audible from the nurses' station and that maintenance had not been asked to adjust the alarm volume following the incident.