Elopement of High-Risk Resident Due to Inadequate Response to Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe, hazard‑free environment for a resident with known elopement risk, resulting in an elopement from a secured unit. The resident, who had vascular dementia, generalized anxiety disorder, and was moderately cognitively impaired with a BIMS score of 9, had documented behaviors of wandering, exit seeking, and occasional resistance to care. The resident resided on a secured unit with alarms on all exit doors and had been assessed as at risk for elopement and wandering on formal Elopement and Wandering Risk Assessments, as well as on the MDS, which documented wandering behavior on four to six days during the seven‑day look‑back period. The facility’s own elopement policy defined elopement as a resident who is not capable of protecting themselves from harm leaving the facility unsupervised and unnoticed. On the night of the incident, during the 11:00 P.M. to 7:00 A.M. shift, the resident exited the secured unit through an alarmed exterior door at approximately 2:10 A.M. Staff on duty, including a nurse and two CNAs, heard an alarm but initially assumed it was triggered by the nurse leaving the unit through the interior door to the lobby to obtain supplies, rather than the exterior exit door. One CNA reported that he did not initially hear the alarm because a loud television was on near where he was documenting, and only heard it once he moved closer to the nurses’ station. The other CNA stated she heard an alarm around that time and believed it was the lobby door alarm associated with the nurse’s departure, and only upon leaving a resident room did she realize the alarm was coming from the exterior exit door. After staff recognized that the alarm was from the exterior door, they conducted a search of the unit and discovered the resident was missing. A facility‑wide missing resident protocol (Dr. Hunt) was initiated, 911 was called, and staff searched outside and in the parking lot. The resident was ultimately located off facility premises at the end of the block by police, with a staff member present. The resident was transported to the hospital ED, where evaluation determined there were no signs of hypothermia, and the resident was later returned to the facility. The DON stated that the secured unit is intended for residents with exit‑seeking behaviors and acknowledged that staff had mistaken the alarm for the lobby door alarm and that the exterior door alarm was not loud enough to be heard throughout the unit, while both doors shared the same alarm sound.
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