Failure to Prevent Resident Elopement Due to Inadequate Supervision and Faulty Door Alarm
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with moderate cognitive impairment. The resident, who had diagnoses including heart disease, chronic kidney disease, and diabetes, was assessed as not being at risk for elopement or unsafe wandering on multiple occasions. Despite these assessments, the resident was able to exit the facility unsupervised by using a motorized wheelchair to force open the front lobby doors, which were found to be off their tracks and not properly alarmed at the time of the incident. Staff discovered the resident outside in the parking lot after a staff member returning from a break noticed the individual in their wheelchair. The resident was confused, had a pile of belongings in their lap, and required assistance to return to their room. Upon investigation, it was determined that the door alarm was not functioning, and no alarm had sounded during the event. The resident had no recollection of leaving the building and did not sustain any injuries. Interviews with staff confirmed that the behavior was new for the resident and that there were no prior indications of elopement risk. The facility's policy required vigilant supervision and timely response to alarms, as well as a systemic approach to monitoring residents at risk for elopement. However, the failure of the door alarm and lack of adequate supervision directly contributed to the resident's unsupervised exit from the facility.