Failure to Maintain Functional Exit Door Alarms Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to maintain exit doors and related elopement alarm systems in good repair to prevent elopement of a resident identified as an elopement risk. The resident had multiple diagnoses including dementia, psychotic and mood disturbances, unsteady gait, history of falls, and a documented history and pattern of goal-directed wandering and elopement or attempted elopement. Progress notes documented that on two consecutive days the resident had previously gone out or attempted to go out the dining room doors and had to be redirected back into the facility. The resident wore elopement alert bracelets intended to lock and alarm exit doors when in proximity. On the night of the elopement, staff last observed the resident sitting in front of the nurse station shortly before he was discovered outside. An anonymous neighbor alerted the facility that the resident had walked out of the building, and he was subsequently found at the end of the driveway near the entrance sign with his walker, fully dressed in outdoor clothing. Staff reported that no door alarms sounded to alert them when the resident exited. There was no documentation that staff checked the resident’s alert bracelets or the functioning of the exit doors and alarm systems at the time of the elopement. Subsequent review and interviews revealed that the facility’s exit door alarm systems, including the Wander-guard and other door alarms, were functioning inconsistently. Maintenance staff acknowledged that weekly alarm checks showed doors sometimes required multiple attempts to function properly and that some issues could not be fixed. Observations by surveyors showed that when elopement bracelets were brought near the front door, the door did not consistently lock or alarm, and staff could exit while holding the bracelets without activation. The front door was sometimes left ajar and therefore did not lock or alarm, and the dining room door’s different alarm system would sometimes alarm without locking and at other times neither lock nor alarm. Staff interviews confirmed that doors were fairly easy to open, did not always close fully, and that no alarms sounded on the night the resident left the building.
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