Failure to Maintain Secure Exit Doors and Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident identified as being at high risk for elopement. The resident had a history of severe cognitive impairment, vascular dementia, and other medical conditions, and was assessed as a high elopement risk with a care plan that included the use of a wander guard device and regular checks. Despite these interventions, the resident was able to exit the secured unit through a second-floor door, as the alarms and delayed egress mechanisms on the exit doors were not functioning properly. The wander guard alarm did sound, but the search for the resident was initially focused inside the building, delaying the discovery that the resident had left the premises. Observations and interviews revealed that the exit discharge door's alarm had not been working for an extended period, and this malfunction was not reported or addressed through the facility's maintenance system. Staff interviews indicated that the door alarm was frequently triggered by the resident, and staff would reset the alarm without ensuring the underlying issue was resolved. Additionally, a contractor had previously unlocked the exit discharge door and failed to relock it, further compromising the security of the unit. The lack of proper signage indicating the delay time on the doors and the absence of a functioning alarm on the exit discharge door contributed to the resident's ability to elope undetected. Documentation showed that the resident was found outside the facility in a parking garage after an internal search and a delayed external search. The facility's policy required immediate action and notification of authorities in the event of a missing resident, but the initial response focused on searching inside the building. The failure to maintain functioning safety devices and to promptly identify and address the malfunctioning alarm system directly led to the resident's elopement.
Removal Plan
- Management-level staff oversight of the facility.
- Monitoring the physical building for functioning egress doors.
- Assessing and monitoring residents with elopement risk.