F0726

J

Failure to Respond to Exit Door Alarms Leads to Resident Elopement and Injury

Bradenton, Florida Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure nursing staff were knowledgeable and competent to respond appropriately to exit door alarms, resulting in an elopement. A resident with dementia and severe cognitive impairment, admitted with diagnoses including dementia with psychotic disturbance, depression, delusional disorder, falls, muscle weakness, lack of coordination, and hallucinations, had documented elopement risk. Elopement risk assessments showed scores at or above the facility’s threshold for exit-seeking and wandering, and progress notes described the resident as confused, disoriented, impulsive, wandering, agitated, and difficult to redirect. Therapy and provider documentation indicated the resident had a shuffling gait, muscle weakness, unsteadiness on feet, and required assistance and a walker for safe ambulation. Staff, including the MD and NP, described the resident as having advanced dementia, high risk for elopement and falls, and appropriate for a memory care setting.

On the night of the incident, the resident was last seen in bed asleep around 2:30 a.m. by the assigned CNA. Shortly thereafter, the resident exited his room, walked down the hallway past the elevator and nurse’s station, and pushed on an alarmed stairwell exit door near the therapy gym. Video reviewed by the Director of Plant Operations showed the resident walking down the therapy hallway holding the handrail, leaning on the exit door, triggering the alarm, and then exiting through the door after the 15‑second delay while the alarm and audible message sounded. The resident then descended two flights of stairs and exited through another alarmed door on the first floor to the outside of the building. The alarms on both the second-floor and first-floor doors were described by multiple staff and maintenance as loud and audible in the nearby nurse’s station areas, with flashing lights indicating which door was alarming.

Despite the alarms sounding, nursing staff did not initiate the facility’s elopement protocol. The supervising LPN on duty went to the wrong exit door, attempted to silence the alarm but could not recall the code, and assumed the alarm was malfunctioning. She contacted maintenance and communicated to other staff that the alarm was a malfunction, leading staff, including the assigned CNA and another RN, to believe it was not a true elopement event. No immediate head count, search of the building, or outside check was initiated at the time the alarm sounded. The assigned CNA was on break when the alarm activated, did not verify the resident’s presence upon returning, and recalled that the alarm continued to sound but did not prompt him to check his residents because he believed it was another malfunction similar to a prior event. Another LPN on the unit heard an unfamiliar alarm sound for a few minutes but did not recognize it as an exit alarm, did not know where it originated, and reported she had never completed elopement drills and was not familiar with the alarm sound.

Maintenance staff arrived approximately 15–20 minutes after the initial alarm, found only the therapy hall stairwell door alarming, and successfully reset it, confirming there was no malfunction. First-floor staff reported not hearing the alarm unless they were near the specific door and did not become aware of the situation until law enforcement arrived. Law enforcement records indicated that the supervising LPN acknowledged receiving an open door alarm around 3:00 a.m. but “thought nothing of it, almost ignoring it,” and that no one was covering the watch role while a staff member was on break. The resident was found off premises by local police in a nearby neighborhood, wet from rain, shivering, and with a laceration above the left eyebrow and a skin tear on the left elbow after a fall. EMS documentation and emergency room records confirmed the resident had been missing from the facility for approximately two hours before being located and transported to the hospital for evaluation and treatment. The surveyors determined that staff’s failure to recognize and respond appropriately to the exit door alarms and to follow elopement procedures constituted a lack of competency in providing care and services to prevent elopement for this resident.