Resident Elopement Through Unalarmed Service Hall Exit Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secure exit and adequate supervision, resulting in a resident eloping through a service hall exit door without staff knowledge. A floor technician (Floor Tech A) used the service hall exit door, which was equipped with a keypad lock and a separate keyed alarm, and exited the building without ensuring that a second staff member (a spotter) was present to monitor the door while it was unalarmed. Video footage reviewed by the Assistant Administrator showed that at 11:32 A.M. Floor Tech A turned the keyed alarm off, entered the keypad code, opened the door, and exited the facility. No staff member remained at the door to monitor it, and Floor Tech A did not re-enter through that door, leaving the door unalarmed and unsecured. The resident involved, identified as Resident #5, had diagnoses including paranoid schizophrenia, chronic pain, and generalized anxiety disorder. The resident’s elopement risk assessment, completed shortly after admission, indicated no prior history of elopement or attempts, no expressed desire to go home, no packing of belongings, no exit-seeking behavior, and no wandering, and the resident was assessed as low risk for elopement. The care plan documented that the resident was at risk for moving around, nervousness, pacing, and restlessness related to anxiety, and directed staff to offer activities and provide protective oversight with supervision for ADLs. The quarterly MDS showed the resident was cognitively intact, did not wander, had no functional limitations in movement, and was independent in ambulation and mobility. On the day of the incident, the service hall was accessible to residents from a common area called the Hangout, which residents used for activities and meals and which opened to the service hall containing vending machines and access to locked resident units. After Floor Tech A exited and left the service hall exit door unalarmed, video footage showed that at 11:35 A.M. the resident entered the service hall from the Hangout and attempted to open the service hall exit door by pushing down the handle, but the door did not open and the resident walked away. At 11:50 A.M., the resident returned, pushed the door handle again, and this time the door opened without triggering an alarm, allowing the resident to exit to the back of the facility. The resident then walked around the building, proceeded approximately two blocks, crossed a four-lane highway, and sat in the grass near dumpsters behind a local coffee shop. Staff, including the charge LPN and the CNA assigned to the resident’s hall, were unaware that the resident had left the building until the local police department notified the Administrator that the resident was at the coffee shop. Staff documentation of hourly face checks recorded the resident as being in the building shortly before and after the time the resident was seen on video exiting through the service hall door, and no staff reported observing the resident leave the facility.
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