Failure to Respond to Door Alarm Results in Resident Elopement
Penalty
Summary
A deficiency occurred when staff failed to respond appropriately to a door alarm, resulting in a resident at risk for elopement exiting the facility unattended. The resident, who had diagnoses including dementia, depression, and anxiety disorder, was non-ambulatory but able to self-propel in a wheelchair and wore a wanderguard daily. The care plan identified the resident as a wander and elopement risk, with interventions in place such as checking the wanderguard function and placement regularly. Despite these measures, the resident was able to push open an emergency exit door that was not equipped with a wanderguard alarm, exit the building, and was found outside by an off-duty staff member. Staff heard the emergency door alarm but did not witness the resident leaving or immediately check the surrounding area outside the door. The investigation revealed that staff did not exit through the door to search for the resident after the alarm sounded, and some staff were unaware of the code needed to reset the exit door alarm. Facility policies for missing residents and secured exits were requested but not provided. The incident was confirmed through interviews, facility documentation, and review of the resident's clinical records.