F0689

J

Failure to Secure Nonfunctioning Exit Door Alarm Resulting in Resident Elopement

Aurora, Illinois Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent a cognitively impaired resident from eloping through an exit door whose audible alarm was known by staff to be nonfunctioning, and the failure to secure that door in accordance with facility policy. The resident was an older adult with unspecified dementia, severe cognitive impairment per the MDS, and multiple significant medical diagnoses including a history of fractures, COPD, and chronic diastolic and systolic CHF. The MDS showed the resident required assistance with multiple ADLs, including supervision for ambulation with a walker up to 50 feet, and walking greater than 150 feet was not attempted due to medical or safety concerns. Despite this, the resident was able to leave the building undetected through the unalarmed Unit B exit door and was later found outside by staff.

On the day of the incident, staff on Unit B, including the assigned CNA and the RN, were aware from shift report that the Unit B exterior door alarm was not working, and they had also been informed earlier in the week that the same door alarm was not functioning. The RN on Unit B spoke with the resident at the nurses’ station as the resident was leaving the dining room with a walker and observed the resident continue walking down the hall toward the B wing exit door near a specified room, even though the resident’s own room was located on a different hallway. The resident was not redirected away from the unalarmed exit door. The RN reported that the door alarm panel at the nurses’ station only displayed a red flashing light when an exit door was opened, that the panel was behind her, and that she did not hear any audible alarm when the resident exited, so she did not look at the panel.

A CNA working on Unit A later observed the resident standing alone outside the Unit A exit door and notified staff on Unit B. Two CNAs from Unit B and the CNA from Unit A went outside through the Unit B exit door, which opened without sounding an alarm, and found the resident outside by the Unit A exit door. The CNAs described the resident as weak, repeatedly stating “I’m cold,” with skin cold to the touch, and too weak to continue walking, requiring use of a wheelchair to return inside. The resident later recalled going out a door into the cold, not knowing how to get back in, walking until finding a door with a window, and knocking until someone came, stating that it felt like a long time and that the resident began saying prayers hoping someone would come. The physician was not notified of the elopement, and there was no incident report, investigation, or progress note documented in the medical record at the time of the occurrence, despite facility policy requiring notification of the attending physician/NP, full body assessment with vitals, and documentation in the medical record following an elopement.

The facility’s written policy on Door Alarm Function Test states that when alarms are nonfunctioning, the door must be made secure by placement of an additional temporary alarm or added supervision until repair is made. Staff interviews confirmed that the Unit B exit door alarm was known to be nonfunctioning on the day of the incident and earlier in the week, yet no staff member was assigned specifically to monitor the exit door, and there were only three staff on the 2 PM–10 PM shift on that unit. The resident walked approximately 195 feet from the Unit B nurses’ station, where last observed by the RN, to the location outside where the resident was found, without being observed or redirected by staff. The attending physician later stated that the physician had not been informed that the resident had exited the facility unnoticed and acknowledged that the resident leaving unsupervised had potential for harm due to risk of injury related to falls or becoming disoriented and lost.