Failure to Prevent Elopement Due to Malfunctioning Door Lock and Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident identified as an elopement risk. The resident, who had a diagnosis of unspecified dementia with behavioral disturbance and a BIMS score indicating cognitive impairment, was care planned as an elopement risk and wore a code alert bracelet. Despite these measures, the resident was able to exit the facility unsupervised and was found across the street in a convenience store parking lot. The facility had a plan to monitor the front door, which was equipped with a magnetic lock and an alarm system intended to activate and lock the door when a resident with a code alert bracelet approached. On the day of the incident, the alarm sounded as the resident neared the door, but the door failed to lock due to a misaligned magnet caused by a loose screw. Staff interviews revealed that, although the alarm was heard and staff responded, the resident had already left the premises and was outside for approximately 15 minutes before being located and returned to the facility. Further review indicated that there was no specific policy or procedure for staff to follow when the alarm was triggered, aside from a general policy for when a resident leaves the building. Staff were aware of which residents wore code alert bracelets and understood the risks associated with unsupervised elopement, but the lack of a functioning door lock and clear procedures contributed to the resident's ability to leave the facility without supervision.