Failure to Prevent Elopement Due to Inoperative Security System and Lack of Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including psychosis and malnutrition, was able to elope from a secured dementia unit. The resident, who was non-English speaking, confused, and required staff supervision for ambulation, was observed outside the facility and subsequently found walking in the road of a heavily traveled highway. The facility's elopement risk assessment for this resident was inconsistent with other documentation, incorrectly stating the resident was not physically able to leave the building and was not confused or disoriented. The incident was facilitated by a malfunctioning elevator security system, which had not been operational for several weeks. The elevator, which should have required a key card for access, was in a fail-safe mode that allowed anyone to use it without restriction. Staff and maintenance confirmed that the system had been reported as broken, and the security vendor had notified the facility that the system was beyond repair, but no action was taken until after the elopement event. Additionally, there was no staff monitoring the elevator or the front desk at the time of the incident, and the front door was unlocked early in the morning, further enabling the resident's exit. Multiple staff interviews revealed that the lack of supervision and the nonfunctional security system directly contributed to the resident's ability to leave the unit and the building unsupervised. The resident was not noticed missing until observed outside by a staff member, and the police were called only after an unsuccessful search by facility staff. The police report and staff statements confirmed that the resident was found walking in the wrong direction in traffic on a busy highway, approximately two miles from the facility, and that there had been previous issues with the security system not restricting access to the dementia unit.