Failure to Prevent Elopement Due to Malfunctioning Exit Door and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, hallucinations, and a history of exit-seeking and wandering behaviors eloped from the facility without staff knowledge. The resident was able to exit through an unlocked and unsecured door on C Hall that malfunctioned and did not trigger an alarm. The resident left his wheelchair at the door, traveled down a steep embankment, and was found on the ground near a two-way street by a passerby, having sustained head injuries that required hospital evaluation. At the time of the incident, the temperature outside was 37 degrees Fahrenheit, and facility staff were unaware that the resident had left the building until notified by local law enforcement. Review of facility policies indicated that residents at risk for wandering or elopement were to be monitored and necessary precautions taken to ensure their safety. However, documentation and staff statements revealed that the exit door alarm did not function properly, and the door had a history of malfunctioning for close to a year. Additionally, window alarms in a resident room near the exit were found to be nonfunctional during a subsequent facility tour, and other doors and hardware were observed to be in disrepair or not properly secured. Staff interviews confirmed that no alarm sounded when the resident exited, and the maintenance director acknowledged longstanding issues with the door's closure mechanism. The facility's failure to provide adequate supervision and maintain a secure environment resulted in the resident's unsupervised exit and subsequent injury. The incident was not immediately detected by staff, and the resident was only discovered after being found by a member of the public and reported to the police. The facility's lack of effective monitoring and failure to address known safety hazards with exit doors and alarms directly contributed to the resident's elopement and injury.