Elopement and Fall Injury Due to Unalarmed, Unlocked Exit Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a safe environment to prevent the elopement of a resident who was known to be at risk for wandering and elopement. The resident had diagnoses including Alzheimer’s disease, dementia, and depression, with a recent MDS showing severely impaired cognition and a need for assistance with all functional abilities. Multiple elopement risk assessments over several months identified the resident as being at risk for elopement, and the care plan reflected this risk with interventions such as assessing for unmet needs when wandering or exit seeking, redirecting and distracting the resident, and use of a Secure Care alarming bracelet device. The resident was also assessed as being at high risk for falls, with care plan interventions addressing fall prevention, including appropriate footwear, clear pathways, and assistance with transfers and toileting. Despite these identified risks and care-planned interventions, the resident was able to leave the building through an exit door in the main dining room that was neither locked nor alarming at the time of the incident. The resident was last seen in her room at approximately 2:00 A.M. by a CNA and was discovered missing at 3:00 A.M. during staff rounds. A search was initiated, and the resident was found at 3:15 A.M. lying in the grass on facility property to the rear of the building. The resident had been propelling herself in a manual wheelchair through the grass and, when attempting to walk, her foot became stuck, causing her to fall to the ground. The investigation determined that the resident exited through a dining room exit door whose alarm and lock failed due to a loss of power. The main power supply to the door had failed, and the backup battery, which should have maintained the lock and alarm, had been drained because the power supply in the attic was intermittently dislodged following storms earlier in the week. Although the maintenance director reported that he had checked all doors after a prior power outage and found no doors beeping on backup power, the specific dining room door later showed no illuminated panel, indicating a power issue. As a result of exiting through this unalarmed and unlocked door, the resident sustained an acute mildly displaced fracture of the right distal fibula at the ankle, as confirmed by x-ray, and also had swelling and pain in the right ankle and knee and a bruise on the right palm.
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