Resident Elopement and Injury Due to Unsecured Exit Door
Penalty
Summary
A deficiency occurred when a resident with a history of diabetes mellitus, chronic kidney disease, and spinal stenosis exited the facility through an unlocked rear Dining Room door and was missing for approximately one and one-half hours before staff became aware. The resident, who had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment, was found to have left the facility in her wheelchair and was later discovered at a nearby hospital emergency department after sustaining a fall and injuries, including facial lacerations and contusions. The incident was captured on facility camera footage, which showed the resident leaving through the rear Dining Room door, crossing the street, and moving out of camera view. Prior to the incident, the resident had not been assessed as being at risk for elopement, as indicated by multiple Elopement/Wandering Risk Assessments completed before the event, all scoring below the threshold for elopement risk. The resident had intermittent confusion and was ambulatory with assistance, including the ability to self-propel in a wheelchair. The facility had equipped the resident with a wheelchair alarm that sounded when she stood up, but there was no Wander Guard device in place before the incident. The rear Dining Room door, through which the resident exited, did not have an alarm or Wander Guard system at the time of the event. Staff became aware of the resident's absence during the dinner tray pass, after which a search was initiated, and the resident was eventually located at the hospital. Interviews with staff and administration confirmed that the rear Dining Room door was not considered a hazard prior to the incident, as the resident had not previously attempted to leave the facility. The door was not locked or alarmed, and its status as an exit was misunderstood among staff, with some believing it was not a designated fire exit. The lack of adequate supervision and environmental safeguards contributed to the resident's unsupervised exit and subsequent injury.