Failure to Secure Exit Doors Leads to Resident Elopement
Penalty
Summary
Facility administrative staff failed to ensure that all locked exit doors were properly secured, resulting in a resident with impaired cognitive function, dementia, and blindness being able to exit the building without staff knowledge. The resident, who had a history of exit-seeking behavior and was identified as at risk for elopement and falls, was able to leave his room, navigate through several hallways and rooms, and ultimately exit the facility through the maintenance office door. The door's electronic lock was not functioning due to dead batteries, which allowed the resident to leave the premises undetected. The resident was missing for approximately 45 minutes before staff became aware of his absence. During this time, the resident was found outside on the facility grounds near the dumpster, lying on the cement sidewalk. The resident was fully clothed and was discovered by a CNA who was on break and heard the resident calling for help. Upon discovery, the resident was assessed and found to have bruising on his right flank. Documentation and staff interviews confirmed that the resident had previously demonstrated exit-seeking behavior, including attempts to leave the facility and statements expressing a desire to go home. The failure to maintain functional security on exit doors and to provide adequate supervision directly contributed to the resident's unsupervised exit and subsequent exposure to potential harm.