Failure to Respond to Door Alarm Results in Resident Elopement
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and did not respond appropriately to a door alarm on a locked unit, resulting in a resident leaving the facility unsupervised. The resident involved had a complex medical history, including paranoid schizophrenia, bipolar disorder with psychotic features, dementia, and other mental health diagnoses. The resident was known to wander, had a history of pushing code pads at doors, and was identified as an elopement risk due to impaired cognition and competence. The care plan included interventions such as distraction, structured activities, and supervision, but the resident did not exhibit exit-seeking behavior prior to the incident. On the day of the incident, the resident exited the facility through a fire door at the end of a hallway that was not visible from the nurse station or dining room. The door could be opened by pressing on the handle for 15 seconds, which triggered a loud alarm. A certified nurse assistant heard the alarm, checked the door, did not see anyone outside, and turned off the alarm, assuming it was set off by the wind. The staff member did not notify the nurse or conduct a head count, and the resident was not signed out for a leave of absence. The resident was later found at another facility after walking approximately 75 feet outside, and staff only became aware of the elopement when contacted by the other facility. Interviews with staff and the resident confirmed that the alarm sounded when the resident exited, but no staff were present in the area at the time. The resident stated she left to inquire about moving to another facility and was not supervised during her time outside. The facility's policies required staff to investigate and report missing residents and to notify supervisors if a resident left without being properly signed out, but these procedures were not followed during the incident.