Failure to Prevent Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
Two residents eloped from the facility on separate occasions by exiting through the front door without staff knowledge. In both incidents, the residents were mistaken for visitors by staff members, which allowed them to leave the premises unsupervised. The facility's front door alarm system was bypassed using an employee's badge, enabling the door to be opened without triggering an alert. In the first incident, a resident in a wheelchair independently left the facility when a visitor opened the front door, and was later found sitting outside alone. In the second incident, another resident, also in a wheelchair, exited the facility when two CNAs held the door open after their shift, not recognizing her as a resident or being aware of her elopement risk status. The first resident had a moderate cognitive impairment with a BIMS score of ten and diagnoses including hypertension, venous thrombosis, TIA, and tachycardia. Although his initial elopement risk evaluation determined he was not at risk, he was found outside alone and was unaware of his location or the events when interviewed. The second resident had a severely impaired cognition with a BIMS score of three, a history of wandering, and was identified as high risk for elopement. She was found outside with another resident who was permitted to go out alone, but she herself was not allowed to do so without staff supervision. She did not recall the incident during her interview but was aware that she needed staff accompaniment to go outside. Staff interviews revealed a lack of awareness regarding which residents were at risk for elopement, despite the existence of an elopement binder with photos and information at key locations in the facility. Some staff members, particularly newer employees, were not familiar with all residents or had forgotten about the elopement binder and its purpose. The front door's security system was compromised by staff badges, which allowed residents to exit undetected when accompanied by staff or visitors. These actions and inactions led to the failure to provide adequate supervision and prevent accident hazards, resulting in the deficiency.