Resident Elopement and Fall Due to Propped Open Door
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a high risk for elopement exited the facility through a side door that had been propped open by a kitchen staff member. The resident, who had diagnoses including anxiety and vascular dementia and a BIMs score indicating severe cognitive impairment, was able to leave the building unsupervised due to the door being left open. The resident subsequently fell on uneven ground outside the facility and sustained cuts and abrasions, requiring transport to a hospital for evaluation and treatment. The incident was discovered when dietary staff notified nursing staff of the resident's fall outdoors. Facility records indicated that the door was propped open for less than a minute while the staff member took out the trash, but this lapse in protocol allowed the resident to exit unnoticed. The staff member acknowledged breaking facility policy by leaving the door open, which had been locked for safety reasons. The event was reported to the state health department as required.