Failure to Secure Kitchen Allows Cognitively Impaired Resident Unsupervised Access
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and to provide adequate supervision when a resident with severe cognitive impairment accessed the main kitchen unattended during nighttime hours. The resident had diagnoses including dementia and anxiety, and an MDS dated August 22, 2025, documented a BIMS score of 3, indicating severely impaired cognition. On the evening of August 27, 2025, the resident, who was on the third floor at 8:30 p.m., was later found missing at 8:45 p.m. when staff could not locate her and a fire alarm sounded. According to the facility’s investigation, staff responding to the fire alarm found the resident in the first-floor kitchen, seated in her wheelchair, stating she had been looking for a snack and that she had pulled something without knowing what it was. The investigation determined that the resident had accessed the kitchen after hours when kitchen staff had left but failed to lock the kitchen. Observation of the first-floor kitchen showed that the fire alarm pull switch was located in the middle of the kitchen, beyond the stove and other kitchen equipment, with two fire doors and one regular door next to the switch leading to the exterior of the building. The Administrator confirmed that the kitchen should have been locked after kitchen staff left and that it was not locked on the night of the incident, allowing the resident to enter the kitchen and activate the fire alarm pull switch.
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