Resident Exited Facility Through Unsecured Patio Door Due to Inadequate Supervision
Penalty
Summary
A resident with moderately impaired cognition, as indicated by a BIMS score of 12 out of 15 and diagnoses including diabetes mellitus, dementia, Parkinson's disease, and encephalopathy, was able to exit the facility into a patio area without staff knowledge. The resident required varying levels of assistance with daily activities and was identified as an elopement risk with a history of wandering. The resident's care plan included interventions for wandering, such as offering diversional activities and monitoring a wander management device, which was in place and functioning at the time of the incident. The incident occurred when the resident exited through an unalarmed patio door that was supposed to remain locked but had not been relocked after use by a family member. Staff had not yet completed the required door checks for that shift, which contributed to the resident's unsupervised exit. The resident was outside for a short period before being noticed and assisted back inside by staff. Facility documentation and staff interviews confirmed that the door was not secured as required, and the care plan did not include additional interventions for wandering beyond those already in place.