Failure to Secure Exit Door Results in Resident Elopement
Penalty
Summary
A deficiency occurred when staff failed to ensure that an exit door was properly secured after use, resulting in the elopement of a resident. On the day of the incident, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) exited the facility through an employee service door with a keypad lock to smoke. Both staff members acknowledged that the door sometimes does not latch unless it is pulled closed, and neither could confirm if the door was properly locked when they left. Shortly after, the CNA observed the resident, who has diagnoses including dementia, Alzheimer's disease, cognitive decline, and repeated falls, in the hallway prior to their exit. Upon returning, the CNA heard knocking and found the resident outside, knocking on their room window. The resident was then brought back inside by staff. The resident later confirmed that they had followed the staff out the door and were unable to re-enter the facility after the door locked behind them. The facility's policy requires staff to be aware of residents' locations at all times and to ensure their safety, but this was not followed, as staff did not verify the door was secured and did not maintain awareness of the resident's whereabouts. The incident was reported to the facility administrator, and interviews with involved staff confirmed the sequence of events and the failure to ensure the door was locked.