Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, type 2 diabetes, anxiety disorder, and acute respiratory failure with hypoxia exited the facility without supervision and walked approximately two miles to a family member's residence. The resident, who had a BIMS score of 12 indicating moderately impaired cognition and was being treated for a urinary tract infection, was last seen in her room after requesting to eat breakfast there. Staff discovered the resident missing during a routine medication pass and initiated a search of the facility and surrounding area. Video surveillance revealed that the resident exited her room using a walker and approached the front door shortly after a delivery person had used the keypad to exit. The resident was observed attempting to use the keypad and successfully opened the door, leaving the facility unsupervised. No staff were present in the hallway or at the front entrance during this time. The resident was later found at a family member's apartment, appearing stressed, lethargic, hungry, dehydrated, with low blood sugar and elevated blood pressure, and was subsequently taken to the hospital. Interviews with facility staff and administration confirmed that the resident had not previously expressed a desire to leave the facility and had not attempted to elope before. Staff also reported that the resident had been seen lingering near the front lobby in the days prior to the incident. The facility's elopement prevention and response policies required staff to report any resident attempting to leave or suspected of being missing, but the resident was able to observe and use the door code without staff intervention, resulting in her unsupervised exit.