Failure to Secure Facility Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure the building was secured to prevent the elopement of a resident with severe cognitive impairment. The resident, who had a Brief Interview for Mental Status (BIMS) score of 0 indicating severely impaired cognition and a diagnosis of schizophrenia, was able to leave the facility without permission. The incident occurred when a window screen in a resident room was found to be loose, allowing the resident to push it open and exit into an outdoor storage area. Staff observed a shoe print near the window, and it was determined that the resident likely used discarded equipment stored in the outdoor area to climb over the perimeter fence. Further investigation revealed that window screens throughout the facility, including the one involved in the incident, were loosely connected and could be easily pulled forward. The outdoor storage area contained large, discarded objects such as bed frames, wheelchairs, and other equipment, which were stored against the perimeter fence and accessible to residents. The Director of Maintenance reported conducting weekly rounds to check for needed repairs but had no documentation to support these checks. Facility policies required maintaining interior surfaces and equipment in good repair and assessing residents for elopement risk, but these were not effectively implemented in this case.