Failure to Monitor and Maintain Functioning Window Alarms in Secure Dementia Unit
Penalty
Summary
The facility failed to ensure that window alarms in a secure dementia unit were adequately monitored and functioning to prevent elopement. A resident with dementia, behavioral disturbances, wandering behaviors, and impaired safety awareness was assessed as cognitively impaired and at high risk for elopement, with a documented history of attempts to leave a previous facility unattended. The resident’s care plan identified elopement risk and wandering, and a wander guard was implemented as an intervention. The resident had a physician’s order to reside in the secured dementia unit. Despite these identified risks and interventions, the resident was able to exit the facility through a window in the secure dementia unit. A progress note documented that the window screen from the resident’s room was found on the ground outside and that the resident had likely exited through the window, walked around the exterior of the building, and then rang the front entrance doorbell to return. The facility’s investigation determined that the resident left the facility unattended through an alarmed window that did not sound when opened, and that the window alarm had malfunctioned. The Administrator and Plant Operations Manager reported that window alarms were visually checked and reportedly tested or had batteries changed approximately quarterly, but they were unable to provide documentation of functional checks for the window alarms in the secure dementia unit.
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