Unsupervised Resident Elopement Through Unmonitored Front Entrance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an unsupervised exit by a resident. The resident had diagnoses including depression, anxiety, congestive heart failure, a heel pressure ulcer, a history of falls, and some memory recall deficits. A recent significant change MDS showed the resident required substantial assistance with toileting hygiene, was dependent for bathing, dressing, and personal hygiene, and used a walker and/or wheelchair for mobility. Despite these needs, a nursing evaluation identified the resident as not at risk for elopement, and there were no prior documented exit-seeking behaviors. On the day of the incident, the resident was last seen by staff in the library near the front door around lunchtime. There was no staff member assigned to the front lobby reception desk on weekends, and staff were responsible for letting visitors in and out of the building. At some point after the last observation, a delivery driver was buzzed out of the facility by an unidentified staff member, and the resident followed. According to the resident’s later statements to the DON, social worker, and a housekeeper, the resident had been watching families come and go, observing the door light and timing how long it stayed green before relocking. The resident reported waiting until a delivery driver was buzzed out, placing a foot in the door, entering the vestibule between the locked interior door and the main exterior door, waiting for the driver to leave the parking lot, and then exiting through the second door. The resident was discovered outside the facility only when a passerby came to the front door and reported seeing an elderly person in a wheelchair across the street in a business parking lot. Staff, including an NA and an LPN, then went outside and brought the resident back into the building. The exact time the resident exited the facility was not known, and staff could only confirm that the resident had last been seen at approximately 12:20 PM and was found outside around 2:00–2:15 PM. Interviews with the DON, RN supervisor, administrator, and other staff confirmed that no staff member admitted to buzzing the delivery driver out, that the front desk was not staffed on weekends, and that although there was an expectation that staff would remain at the door until it closed and relocked and ensure no resident exited, this expectation was not supported by a written policy and was not effectively implemented, allowing the resident to leave the building unattended.
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