Failure to Maintain Courtyard Gate Latch Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that the latch on the courtyard gate was in proper working order, resulting in a resident being able to exit the facility without staff supervision. On the date of the incident, a resident's son and an LPN went outside to the fenced-in courtyard and discovered that the gate was neither locked nor latched. The resident was later found outside the facility by a member of the public, who contacted the facility to report the situation. The resident's son expressed concern about the safety of the facility, specifically citing the unsecured back fence as a reason for feeling unsafe and deciding to take his mother home. Interviews and record reviews confirmed that the latch to the gate off the 200-hall exit door was broken at the time of the incident. The Director of Nursing acknowledged that the latch was not functioning and stated that staff were told it was not required to be latched. Facility policy indicates a commitment to maintaining an environment free from accident hazards and prioritizing resident safety and supervision. At the time of the incident, there were 50 residents residing in the facility.