F0689

J

Failure to Respond to Exit Alarms Leads to Elopement and Injury of High-Risk Resident

Bradenton, Florida Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to respond to two exit door alarms and provide adequate supervision to prevent a severely cognitively impaired, high fall- and elopement-risk resident from exiting the building. The resident had dementia with psychotic features and delusions, severe cognitive impairment with a BIMS score of 6, impaired decision-making, a documented determination of incapacitation, and multiple diagnoses including myasthenia gravis, atrial fibrillation on anticoagulation, depression, delusional disorder, and muscle weakness. Care plans and assessments identified the resident as at high risk for falls and at risk for elopement and wandering, with documented wandering, impulsivity, agitation, difficulty with redirection, and unsteadiness on his feet. Therapy notes showed he required supervision or touching assistance and contact guard assist for transfers and gait due to poor safety awareness and high fall risk.

On the night of the incident, the resident was last seen around 2:30 a.m. in bed asleep by his assigned CNA. Shortly thereafter, an emergency stairwell exit door alarm by the therapy department on the second floor sounded. The supervisor LPN, who was on the second floor at the time but assigned to the first floor, went to the wrong door near the wound care nurse’s office, attempted to silence the alarm but could not recall the code, and assumed the alarm was malfunctioning. She contacted maintenance rather than initiating the facility’s elopement policy, which required calling a code purple, conducting an immediate search, checking outside, and completing a head count. Another LPN on the unit heard the alarm but was told by the supervisor that it was malfunctioning, and she did not initiate elopement procedures at that time. The assigned CNA was on break when the alarm sounded, received a call from the supervisor asking how to turn off the alarm, believed it was another malfunctioning door based on a similar prior event, and did not check on his residents when he returned from break, even though the alarm was still sounding.

Video footage reviewed by the Director of Plant Operations showed the resident walking down the therapy hallway without a walker or wheelchair, holding onto the railing, leaning on the exit door, triggering the alarm at approximately 2:32 a.m., and then exiting through the stairwell. The resident proceeded down two flights of stairs to a first-floor exit door at the back of the facility, where a second alarm (a red screamer) sounded and later self-terminated after 10–15 minutes. Staff on the first floor reported they did not hear or see anything, and no staff were observed responding to the alarms on the video. The resident then walked approximately 170 yards through the back parking lot, crossed a four-lane road with a 40 mph speed limit, and entered a nearby neighborhood in rainy conditions. Local law enforcement was dispatched around 4:48 a.m. to a neighborhood residence for an elderly male with a head injury knocking on doors; officers identified him as the resident from the memory care unit. He was found soaking wet, shivering, and with a laceration to his left eyebrow and a skin tear to his left elbow from a fall, and EMS transported him to the hospital. EMS documentation indicated the fall occurred about two hours before assessment, and the resident had been missing from the facility for approximately two hours without staff knowledge. The facility’s failure to respond appropriately to the exit door alarms and to supervise the resident in accordance with his known fall and elopement risks resulted in his unwitnessed exit and subsequent injury, and surveyors determined this constituted Immediate Jeopardy.