Failure to Supervise Exit Doors and Investigate Elopement
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment by leaving an exit door and a courtyard gate both unlocked and unalarmed, which allowed a resident with severe cognitive impairment and a diagnosis of dementia to elope from the building unnoticed. The resident, who was independently mobile and had a recent mental status change, was found walking outside along the building perimeter by a Certified Nursing Assistant (CNA) who observed the resident through a window while providing care to another individual. The resident stated they were trying to go home and appeared disoriented, but was able to return to the facility with staff assistance. At the time of the incident, the courtyard gate was left open and unlocked due to a mowing contractor's access, and the hallway exit door was routinely kept unlocked and unalarmed to allow residents who smoke to access the courtyard without staff supervision. The facility's elopement investigation did not identify or document the root cause of the incident, nor did it note that the exit door and courtyard gate were unsupervised, unlocked, and unalarmed at the time of the elopement. The facility's policy requires adequate supervision and a root cause analysis following an elopement, but the investigation failed to address these requirements. The resident's care plan indicated minimal staff assistance was needed for ambulation, but assessments documented severe cognitive impairment and elopement risk factors.