Failure to Monitor Exit Door Results in Resident Elopement
Penalty
Summary
A resident with severely impaired cognition, as indicated by a BIMS score of seven, was admitted to the rehabilitation unit following a hospitalization for syncope and collapse. The resident was assessed as having a moderate risk for elopement due to her mobility, though she had not previously verbalized a desire to leave. On the day of the incident, the resident became upset after a care conference with her family, during which concerns about her ability to return home independently were discussed. Later that day, the resident exited the facility through the front door without staff knowledge. The front door was supposed to be locked and alarmed automatically at a certain time, but prior to that, it was to be monitored by staff. At the time of the elopement, the administrative assistant responsible for monitoring the front door had stepped away to make copies and did not notify other staff to monitor the door in her absence. As a result, the door was left unmonitored and unalarmed, allowing the resident to leave undetected. Staff only became aware of the elopement when a community member called to report that the resident was at their home nearby. Interviews with staff confirmed that rounds were conducted every two hours or less, but no one responded to a door alarm because none was triggered. The facility's elopement procedure required that residents' whereabouts be known at all times, but this was not followed due to the lapse in monitoring the front door. The resident was later found safe and returned to the facility, but the incident revealed a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent accidents.