Failure to Secure Laundry and Mechanical Room Doors Resulting in Resident Injury
Penalty
Summary
Facility staff failed to ensure that the doors to the laundry room and mechanical/boiler room were locked when unattended, resulting in unauthorized access by a resident. On the evening of the incident, a Geriatric Nursing Assistant (GNA) was unable to locate a resident during evening care. After a search, the resident was found in the mechanical/boiler room, sitting on the floor near their wheelchair. The resident sustained a skin tear/laceration on the left shin and bruises on the left forearm and right elbow. The resident involved had a history of cognitive impairment, including diagnoses of Adjustment Disorder, Cognitive Communication Deficit, Delusional Disorders, and late-onset Alzheimer's Disease. The resident was assessed as high risk for elopement, with a severely impaired BIMS score. The resident used a wheelchair for mobility and had a care plan addressing elopement risk, wandering, and impaired safety. At the time of the incident, the resident could not recall how they entered the mechanical room and was disoriented, searching for a deceased spouse. Observations and interviews revealed that the laundry room doors were designed to lock automatically when closed, requiring a keypad code for entry, while the mechanical/boiler room door required a key from the laundry room side but did not automatically lock. Staff statements and maintenance inspection indicated that the doors were likely propped open, allowing the resident to access the unauthorized area. There was no evidence of mechanical malfunction with the door locks at the time of the incident.