Elopement of High-Risk Resident Due to Inadequate Supervision and Nonfunctioning Exit Alarm
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a resident with a known history of elopement and severe cognitive impairment. The resident, who lived on a locked second-floor unit requiring a card key for elevator use, had previously eloped in September 2025 and was care planned and assessed as high risk for elopement, with dementia, impaired thought processes, poor short- and long-term memory, and severe cognitive impairment. The resident’s physician stated the resident was confused and required supervision when leaving the facility, and a psychiatrist note documented a history of auditory hallucinations. On the day of the incident, the resident was last seen at 11:30 AM. At 11:50 AM, a CNA went to the resident’s room to bring him to lunch and could not locate him. Nursing staff initiated a search of the facility, including outside areas, but were unable to find the resident. During this search, an RN checked the basement exit door and found that it did not alarm when opened. Multiple staff members, including the RN, CNA, and receptionist at the main desk facing the elevator and main exit, reported that they did not hear any door alarms around the time the resident went missing, and the receptionist did not see the resident exit via the elevator or main entrance. External reports and interviews confirmed that the resident had left the facility unsupervised. A sheriff’s report documented that the resident was reported missing and was later located offsite, and an employee at a nearby oil change shop reported that a confused man matching the resident’s description arrived there, was not appropriately dressed for the cold weather, and then wandered off, prompting a 911 call. Law enforcement later found the resident at a scrap metal recycling center approximately 1.6 miles from the facility, and a police officer stated the resident would have had to cross three busy, heavily traveled roads to reach that location. Hospital records showed the resident was evaluated in the emergency room for cold exposure. Subsequent testing of the basement exit door by maintenance confirmed that the door alarm did not activate when opened, and maintenance staff stated the alarm should have been activated and must have been turned off.
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