Failure to Secure Exit Doors and Supervise Exit-Seeking Resident
Penalty
Summary
A deficiency occurred when staff failed to maintain secured exit doors and provide adequate supervision for a resident identified as exit seeking. The resident, who had diagnoses including Alzheimer's Disease, non-traumatic brain dysfunction, hypertension, anxiety, and disorientation, was assessed as having moderately impaired cognitive skills and a high risk for falls. Despite these risks, the resident was able to exit the facility through the front door after a housekeeper held the door open for him upon her arrival. The housekeeper did not notify nursing or management staff that the resident had left the building. Following the resident's exit, staff did not immediately realize he was missing. The resident walked approximately 0.8 miles down a highway into town, unaccompanied and without appropriate outerwear for the weather conditions, which were cold at the time. The absence of the resident was only discovered when his family called the facility to report that he had contacted them from a location in town. Staff then initiated a search and contacted the police, who located the resident and returned him to the facility. Upon return, the resident was assessed and found to have cold fingertips but no injuries. Interviews with staff revealed that several employees had observed the resident near the front entrance and noted his exit-seeking behavior earlier that morning. However, interventions to prevent his elopement were insufficient, and communication among staff regarding his whereabouts was lacking. The facility's failure to secure the exit and supervise the resident resulted in the resident leaving the premises unsupervised for approximately 45 minutes.