Failure to Prevent Elopement After Door Alarm Was Silenced Without Investigation
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and ensure adequate supervision to prevent accidents for a resident with known cognitive impairment. The resident was an elderly female with a recent hip fracture and Alzheimer’s disease who reported remembering being outside the building but could not explain why she had gone out. On the evening of the incident, she was found standing outside the facility next to the southeast stairwell door. At that time, she was dressed appropriately for the cold weather except for having only one sock and no shoes. A head-to-toe assessment was completed and revealed no concerns of physical harm, and the resident later stated she was not harmed, felt safe, and would not repeat the behavior. The events leading to the deficiency included a failure by staff to appropriately respond to a door alarm. At approximately 9:00 PM, an RN heard the second-floor door alarm sounding and silenced the alarm without further investigating the cause. About 15 minutes later, the resident was discovered outside near the stairwell door, indicating that the alarm had signaled an actual exit attempt that was not properly assessed. This sequence of events shows that the resident was able to leave the building unsupervised, resulting in an elopement and demonstrating that the area was not kept free from accident hazards with adequate supervision at the time of the incident.
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