Resident with Dementia Allowed to Exit Secured Unit Unsupervised
Penalty
Summary
A resident with dementia and Alzheimer's disease, newly admitted to the secured locked unit, was able to leave the facility unsupervised. The resident was not identified as exit-seeking and had no history of elopement according to the admission assessment. On the day of the incident, a CNA responded to a door alarm and, after interacting with the resident who requested to go outside, allowed the resident to exit through a secured door by entering the code. The CNA mistook the resident for a visitor and did not provide supervision as the resident left the building. The resident was later observed by another staff member walking on a sidewalk away from the facility and was subsequently escorted back. The facility was unaware of the resident's elopement until notified by the staff member who found the resident. Documentation confirmed that the door alarm functioned as intended, but staff failed to follow elopement prevention protocols, resulting in the resident being unsupervised outside the facility for a period of time.