Elopement of At-Risk Resident Due to Inadequate Supervision and Door Alarm Failure
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident who had been identified as at risk for unsafe wandering. The resident had diagnoses including atherosclerotic heart disease, age-related debility, and dementia, with a BIMS score of 8 indicating moderate cognitive impairment. An Elopement Risk Evaluation documented that the resident was at risk for elopement, and the care plan stated the resident would remain safe within the facility unless accompanied by staff or another authorized person. A physician’s order directed staff to monitor the resident’s wandering behavior. Despite these assessments and orders, the resident was able to leave the building unaccompanied. On the day of the incident, the resident exited the facility through a back exit door on one of the units. The resident was last seen inside by a CNA at 5:18 p.m. and was found outside and brought back into the building by an LPN at 5:20 p.m., wearing regular indoor clothing in 50-degree Fahrenheit weather. A progress note documented that the back door opened easily and that only a low alarm sounded while the loud alarm remained silent when the resident exited. An employee statement from a nurse aide described a similar situation in which a male individual, assumed to be a family member, walked toward exit doors and left the building without any alarms sounding, with alarms only activating when he re-entered the facility about ten minutes later. These events demonstrate that the resident, previously identified as an elopement risk, was able to leave the facility due to inadequate supervision and malfunctioning or ineffective door alarm systems.
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