Failure to Prevent Elopement Due to Inadequate Supervision and Door Alarm Bypass
Penalty
Summary
A deficiency occurred when a resident identified as a wander and elopement risk exited the facility unsupervised. The resident, who had a diagnosis of unspecified dementia and mood disturbance, was assessed as moderately cognitively impaired with a BIMS score of 9 and had a documented elopement risk score of 9. Despite being equipped with a wander alarm, the resident was able to leave the facility through a delivery door that was equipped with magnetic locks and an alarm system. The incident took place when the delivery door was left open and the alarm system was not engaged due to an employee accidentally entering a bypass code upon exiting. This allowed the resident to leave the building undetected. The resident was observed outside the facility by staff and was returned after being gone for approximately 14 minutes. At the time of the incident, the resident was appropriately dressed for the weather and was assessed for injury or emotional trauma upon return, with no concerns noted. Interviews and documentation confirmed that the last employee to use the door was a maintenance assistant, and only three staff members had access to the codes for the door, one of which allowed for bypassing the alarm system. The failure to ensure the alarm was properly engaged and to provide adequate supervision for a resident at risk for elopement resulted in the resident leaving the facility without staff knowledge.