Unsupervised Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when a resident with dementia and a high risk of elopement exited a secure unit unsupervised. The resident, who had a history of wandering and moderate cognitive impairment, was able to leave the secure unit after the assigned RN left the area to respond to a code elsewhere in the building. At the time, the only CNA assigned to the unit was on lunch break, leaving the secure unit without staff supervision. The secure unit door did not latch properly behind the RN, allowing the resident to follow and exit the unit. The resident proceeded through a side exit and entered the passenger seat of a parked fire truck in the facility's parking lot. Video footage confirmed that the resident left the secure unit, walked through the building, exited through a side door, and entered the fire truck without any staff or emergency personnel present in the area. The resident was later redirected back to the secure unit by another staff member after being observed near the facility's main entrance. Interviews with staff revealed a lack of clear protocols regarding code response and supervision coverage for the secure unit. The RN who left the unit stated he had not received training on code response teams and believed he was required to respond to all codes, despite no formal direction from the facility. The DON and other staff confirmed there was no policy specific to the secure unit, and staff had not received recent in-service training on elopement prevention or supervision. The facility's failure to ensure adequate supervision and secure door function resulted in the resident's unsupervised exit and placed residents at risk.