Failure to Prevent Elopement Due to Unsecured Office and Window
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia, Alzheimer's disease, and delusional disorders, was able to elope from the facility. The resident had been assessed as an elopement risk and was care planned for a security bracelet. Despite these interventions, the resident was able to leave the facility through a window in an office that had a malfunctioning door lock. The window did not have a stop to limit how far it could open, and the office door was found to be unlocked at the time of the incident. On the day of the incident, the resident was last seen by a CNA approximately 10-15 minutes before being discovered missing. Video footage showed the resident entering the MDS office and not exiting through the door, indicating the resident left through the window. The resident was later found by staff at a convenience store nearly a mile away and was returned to the facility. Upon assessment, the resident had no new injuries, only pre-existing skin tears. Interviews with staff confirmed that prior to the incident, windows in offices and the therapy gym did not have stops, and the office door lock was not functioning as intended. Staff also confirmed that the system in place for securing office doors and monitoring residents at risk for elopement was not effectively implemented at the time, which allowed the resident to exit the building undetected.