F0689

D

Failure to Prevent Repeated Elopement Due to Door Alarm Misuse, Inadequate Monitoring, and Front Desk Lapses

Rockaway Park, New York Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident with depression and schizophrenia, resulting in two separate unsupervised exits from the building. On the first occasion, the resident had been assessed on admission as not at risk for elopement or unsafe wandering and had intact cognition, ambulating with supervision or touching assistance. On the day of the first incident, hourly rounding documentation at 5:00 PM recorded the resident as observed in bed awake. However, facility video later showed the resident walking down the hallway and exiting through the back exit door on the first floor at approximately 5:57 PM, without triggering an alarm. Staff did not realize the resident was missing until about 7:15 PM, when an LPN noted the resident was not in their room prior to medication administration and a search of the unit and facility was initiated.

The first elopement was linked to the actions of a housekeeping staff member who used the back exit door to dispose of garbage and had the key to disable the door alarm. The facility’s policy on the delivery door alarm override limited use of the override key to authorized staff and required continuous supervision of the door and immediate re-arming of the alarm, with no prolonged disarming permitted. Housekeeping staff reported using the back door between 7:00 PM and 10:30 PM and stated they had the key to disable the alarm, believed they had locked the door and re-enabled the alarm, but acknowledged they may have forgotten to lock the door, allowing the resident to exit. The RN Supervisor confirmed that video surveillance showed the resident using the back exit door without triggering an alarm because the housekeeping porter had disarmed it, and the resident left the facility grounds unsupervised.

The second elopement occurred after the resident had a documented history of elopement and was identified as at risk, with a care plan and physician’s orders for a wander guard and frequent monitoring. The MDS continued to show intact cognition and ambulation with supervision or touching assistance. An elopement evaluation documented that the resident had a history of elopement and voiced a desire to leave, and the Kardex indicated hourly rounds and a wander guard on the left wrist. Despite this, there was no documented hourly monitoring for the resident on the night of the second incident. Video surveillance showed the resident leaving the unit, taking the elevator, and later appearing at the front desk wearing a hat, blue jacket, and jeans. The security guard at the front desk pressed the button to unlock the front door and allowed the resident to leave, later stating that the individual did not look like a resident, had refused to sign in or out, and was nonetheless permitted to exit. The facility’s reception policy required all visitors to log in and out and directed reception/security staff not to allow anyone to leave without knowing whether the person was a visitor or a resident. The RN Supervisor and internal investigation documented that the security guard did not initially report the occurrence, and staff later found the resident’s wander guard cut off and left at the bedside, indicating the resident had removed it prior to leaving. These actions and inactions resulted in the resident exiting the facility unsupervised on two separate occasions without the facility’s knowledge at the time of departure.

In both incidents, the facility’s systems and staff practices failed to prevent elopement despite existing policies and, in the second incident, a known elopement risk and specific monitoring and wander guard orders. In the first event, the back exit door alarm was disarmed and not properly managed, allowing the resident to leave without triggering an alarm and without timely detection by staff. In the second event, required hourly monitoring was not documented, the resident was able to remove the wander guard and leave the unit, and the security guard at the front desk did not verify the person’s identity as a resident or visitor before unlocking the front door, contrary to policy, and did not promptly notify nursing staff of the exit. These combined failures in supervision, door alarm management, and adherence to reception and elopement prevention policies led directly to the resident’s two elopements from the facility.