Failure to Maintain Audible Door Alarms and Secure Exit Gate Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure that its door alarms were sufficiently loud to be heard from areas away from the 200 hall exit door, and did not maintain the outside gate latch in working order. This deficiency was identified when a resident with severe cognitive impairment and a history of wandering was able to elope from the facility. Multiple staff and family members reported that the alarm on the 200-hall exit door could not be heard from the 100/300 hall nurse's station until they were much closer to the door, and even then, it was difficult to discern the type of alarm. At the time of the incident, there were no staff present at the 200 hall nurse's station, and the only therapy staff in the building was located at the front of the facility, away from the exit door in question. The resident involved had severe cognitive impairment, Alzheimer's Disease, and was ambulatory with supervision. On the day of the incident, the resident's son was visiting and, after briefly leaving the resident unattended, discovered she was missing. Staff and the son searched the facility and only became aware of the exit when they heard the alarm faintly while approaching the 200 hall. The resident was ultimately found outside the facility, in the roadway behind the building, by a bystander and family members. It was also noted that the gate to the fenced area outside the 200-hall door was not latched, allowing the resident to leave the premises. Interviews with staff and the resident's family confirmed that the alarm was not functioning at an adequate volume and that the gate latch was broken at the time of the incident. Staff also indicated that the alarm was not always audible from key locations within the facility, and the maintenance director acknowledged recent issues with the alarm system. The facility's elopement prevention policy required assessment and interventions for residents at risk, but the failure to maintain effective alarm audibility and secure exits directly contributed to the resident's elopement.