Failure to Prevent Elopement Due to Unsecured Exit Door
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known history of wandering and elopement risk was able to exit the facility without staff knowledge. The resident, who had diagnoses including dementia and age-related cognitive decline, was assessed as severely impaired on the Brief Interview for Mental Status (BIMS) and was identified as an elopement risk in the care plan. The care plan included interventions such as a functioning wander guard device, monitoring for wandering patterns, and providing structured activities. Despite these measures, the resident was able to leave the secured area. The incident took place when the resident accessed an employee breakroom door that was supposed to be locked. However, the door's latch had been blocked by a paper towel, preventing it from locking. This allowed the resident to pass through the breakroom, into a wheelchair supply room, and then out an external door that led to the parking lot and another building. Surveillance footage confirmed the resident exited the facility, walked through the parking lot, and attempted to open a parked car before entering a nearby personal care building. Staff only became aware of the resident's absence after being notified by a hospice nurse aide in the personal care building. At the time of the event, the resident's wander guard was functioning properly, but there were no sensors on the breakroom door, as it was assumed to be secured by a lock. Staff interviews and facility documentation confirmed that the resident was last seen in the dining room area shortly before the elopement and that the doors in question were not properly secured due to the obstructed latch. The facility's failure to ensure that all exit doors were secured and to provide adequate supervision resulted in the resident's unsupervised exit from the building.