Failure to Prevent Elopement Due to Unaddressed Door Malfunction and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent an elopement. A resident with severe cognitive impairment, dementia, and a history of impulsiveness and communication deficits was admitted to the facility. The resident was identified as being at risk for elopement during an initial evaluation, but no care plan addressing elopement was initiated at that time. The resident resided on a secure unit, but the electronic monitoring system was not activated prior to the incident. The deficiency was further compounded by a malfunctioning electronic locking door on the secure unit, which had been known to have intermittent issues for several weeks. Multiple staff members reported problems with the door not locking properly, requiring extra effort to ensure it was secure, and making unusual mechanical noises. Despite these reports, there were no documented maintenance work orders for the door, and the issue was not properly escalated or tracked in the facility's maintenance system. On the night of the incident, the resident was last seen in the hallway and later found to have exited the facility through the faulty door, walking down a city street in traffic with a walker. The facility was initially unaware that the resident was missing, and only after being contacted by local police and further investigation did staff realize the resident had eloped. The police and EMS were involved in locating and returning the resident, who was found unable to communicate their identity. Interviews with staff revealed inconsistent reporting and follow-up on the door's malfunction, as well as a lack of clear documentation and communication regarding maintenance issues. The facility's policy required immediate notification and monitoring of malfunctioning exit doors, but this was not followed, contributing to the resident's elopement.