Failure to Maintain Secure Main Entrance and Respond to Call Light Resulting in Unauthorized Entry and Theft
Penalty
Summary
The facility failed to maintain a safe and functional main entry door, allowing an unhoused individual to enter the building without staff awareness and remain inside. A door service company’s receipt documented that the main entry door closer no longer had latching force, was not closing properly, and the closing force was not responding correctly. The Maintenance Director reported that the front door magnet that should ensure automatic closure was not working properly, and also stated that although doors are checked frequently, there was no maintenance log documenting entrance door checks, despite facility policy requiring maintenance records such as inspection of the building and maintenance schedules. A resident with diabetes mellitus, malignant neoplasm of the endocrine pancreas, muscle weakness, and difficulty walking, who required moderate to total assistance with ADLs but had intact cognitive skills, was affected by this failure. The resident’s family member reported that an unhoused individual entered the facility, stayed and slept in an unassigned bed in the resident’s room, and that the resident pressed the call light multiple times without staff response for a while. The family member stated the resident felt terrified and later discovered her mobile phone was missing. An LVN stated she found the unhoused individual in the resident’s room, noted he appeared homeless and carried a plastic bag, and escorted him out after he claimed to have checked in while holding a mobile phone. The LVN acknowledged ongoing issues with the front door not fully closing and locking from the outside, and also stated she did not document the incident or report it to management or staff. The Administrator confirmed that an unhoused individual entered without staff knowledge and stole the resident’s mobile phone.
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