F0689

D

Failure to Secure Exterior Fire Doors and Implement Elopement Interventions for At-Risk Resident

Putnam, Connecticut Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that exterior fire doors in a resident-accessible area were secured and to provide adequate supervision and interventions for an ambulatory resident assessed as at risk for elopement, resulting in the resident exiting the building unsupervised. The resident was admitted with dementia, repeated falls, and insomnia, had a responsible party, and was identified on an elopement evaluation as being at risk for elopement, with an elopement care plan initiated. The resident care plan documented dementia-related elopement risk, a history of wandering in the community and at the facility, and a past occupation as an elevator repair person with a pattern of thinking he had service calls and wanting to leave at night. Interventions listed included calm introductions, explanation of routines, orientation to room and environment, frequent checks as necessary, a picture in the business office, and encouraging family to bring familiar objects; no wander guard was initiated at that time.

Clinical documentation showed the resident had late evening and early morning wakefulness, agitation, confusion, and wandering, including middle-of-the-night confusion and looking for a family member, with PRN Trazodone ordered for agitation/insomnia. The quarterly MDS identified moderately impaired cognition (BIMS 11), independent ambulation of at least 150 feet, and wandering behaviors occurring one to three days per week. A fall assessment tool identified the resident as high risk for falls. Despite these findings and the facility’s own policy stating that residents identified as elopement risks should have a wander guard bracelet initiated and checked each shift, the DNS stated the resident did not have a wander guard because the resident was not considered exit seeking or making statements of wanting to leave. The DNS also acknowledged that the resident’s room, which was the closest to the exterior fire doors and farthest from the nursing station, was the only room available at admission.

On the night of the event, a bathroom fan fire on another wing had triggered the fire alarm the previous day, which the Maintenance Director stated could cause exterior fire doors to open and then not close and latch properly once the alarm was completed. He acknowledged that no one from maintenance checked the exterior fire doors after the fire alarm to ensure they were secured and latched, and that the D-wing exterior fire doors were known to require being pulled shut to secure, with weather stripping possibly contributing to incomplete closure. In the early morning hours, staff heard an alarm they did not recognize and initially did not know it was from the exterior fire doors; they required direction from the supervisor to check those doors. The NA found the D-wing exterior fire door slightly ajar, closed it, and then began a resident head count, discovering the resident missing from the room nearest the doors. When the exterior doors were opened, the resident—who had been last seen in bed around midnight and was known to pack belongings at night to go home—was found outside on hands and knees. Both the NA and RN reported they had not participated in any elopement drills, and the DNS confirmed the facility had not conducted elopement drills and had no documentation of such drills, despite policy requiring periodic elopement drills for residents at risk for wandering/elopement.