F0689

D

Resident Elopement Through Unsecured Elevator and Exit Door

Springfield, Pennsylvania Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure the resident environment was free of accident hazards when an unlocked elevator allowed access to an exit door through which a resident left the building. Facility policy on Safety and Supervision of Residents required ongoing identification of safety risks and environmental hazards, and the Wandering and Elopements policy required identification of residents at risk of unsafe wandering. Despite these policies, the elevator associated with a newly constructed dialysis suite remained accessible to residents, creating an unmonitored route from a locked unit to an unsecured emergency exit door.

The resident involved, identified as R1, was admitted with diagnoses including dementia and difficulty walking. The clinical record showed a BIMS score of 15, indicating cognitive intactness, but progress notes documented the resident as awake, alert, and oriented x1–2 with forgetfulness, able to recall long-term events but unable to remember what was said 30 minutes to one hour earlier. An Elopement/Wandering Risk Evaluation completed on admission identified the resident as being at moderate risk for elopement.

According to the facility’s investigation and staff interviews, R1 resided on a locked unit but was able to access the elevator due to its availability during the dialysis suite construction. The resident entered the elevator, traveled to the unoccupied dialysis suite hallway, and then pushed on an emergency exit door until it opened, allowing the resident to exit the building while wearing a jacket. The resident proceeded toward a nearby bus station and was observed by staff boarding a public bus, at which point staff approached and assisted the resident back to the facility.