RIVERBANK, CA - A resident with severe cognitive impairment walked out of Riverbank Post-Acute undetected and was found blocks away near a highway, prompting state inspectors to discover that a critical exit door alarm had been non-functional for an extended period.
Security Systems Failed to Prevent Dangerous Elopement
On April 28, 2024, a resident with documented exit-seeking behaviors left Riverbank Post-Acute through an alarmed door that should have immediately alerted staff. The resident, who had severe cognitive impairment and paralysis affecting one side of their body, was discovered at 6:35 a.m. wheeling themselves down the street away from the facility. Staff located the individual approximately 10 minutes later, but it took more than 30 minutes to redirect them back to the facility, with the resident finally returning at 7:17 a.m.
The resident had crossed a highway and reached a church parking lot before being found. Medical records indicated the individual had been diagnosed with conditions including palliative care status, hemiplegia following a stroke, chronic brain bleeding, and cachexia—a severe wasting condition associated with chronic illness. Their cognitive assessment score of 6 out of 15 indicated severe impairment, placing them in the highest-risk category for wandering incidents.
Facility records showed the resident was under physician orders to have a wander-guard monitoring device checked every shift specifically to prevent such incidents. Despite these documented safety measures, the resident managed to leave the building without triggering any alarms or staff awareness.
Exit Alarm Non-Functional During State Inspection
When state inspectors tested the facility's exit door alarms on May 15, 2024—more than two weeks after the elopement incident—they discovered a malfunctioning alarm that posed ongoing risks to residents. The exit door near room [ROOM NUMBER], located on the same hallway as the resident who had previously eloped, displayed a red octagon-shaped alarm box with the warning "stop alarm will sound."
During testing with the Director of Maintenance present, inspectors opened the door three separate times. The alarm remained completely silent during each attempt. When asked directly about the alarm's functionality, the maintenance director confirmed "the alarm is not working if I open the door at this moment." Only after removing and repairing the device did the alarm begin functioning properly, producing the expected loud, high-pitched sound.
The malfunctioning exit alarm created a direct pathway for cognitively impaired residents to leave the facility undetected. Exit door alarms serve as a critical last line of defense in facilities caring for residents with dementia, confusion, or conditions that impair judgment. These systems must function continuously because elopement incidents can result in severe consequences including exposure to traffic, weather-related injuries, dehydration, falls, or death.
The medical implications of this failure were particularly serious given the resident's documented conditions. Individuals with hemiplegia face increased fall risk and limited ability to protect themselves from injury. Combined with severe cognitive impairment and exit-seeking behaviors, the lack of a functioning alarm system created a dangerous environment where the resident's documented vulnerabilities were not adequately addressed through facility safety measures.
Staff Unable to Recall Hearing Alarm for Extended Period
Multiple staff members interviewed by inspectors revealed the alarm had likely been non-functional for a considerable time before the inspection. A Certified Nursing Assistant stated she "did not remember the last time she had heard the door alarm go off," despite indicating the alarm was typically "very sensitive and would go off whether the door was touched or not." She confirmed she "had not heard the alarm for a while and was not sure if it was working."
A Licensed Vocational Nurse similarly reported that the exit door alarm "was sensitive and would frequently sound by itself," but confirmed "it had been a while since he had heard the alarm sound." When the repaired alarm was finally tested and produced its characteristic loud sound, the Medical Records Director emerged from her nearby office stating "I do not remember the last time I heard the alarm go off."
These statements indicate the alarm malfunction existed for an extended period before and after the April 28 elopement incident. Standard practice in long-term care facilities requires regular testing of all safety systems, particularly those designed to protect vulnerable residents from wandering. The failure to identify and repair this critical safety device represented a systematic breakdown in the facility's maintenance and safety protocols.
Additional Issues Identified
Inspectors discovered the facility lacked consistent documentation and testing procedures for exit door alarms. While the current Director of Maintenance reported checking alarms weekly, his documentation showed the last test occurred on May 7, 2024—eight days before inspectors found the malfunctioning alarm. The previous maintenance director had only tested doors monthly, creating gaps in safety verification.
The facility's wander-guard system—separate from the exit door alarms—appeared to function properly when tested by inspectors. However, the combination of a non-working exit door alarm and a resident with documented exit-seeking behaviors demonstrated how multiple system failures can compound risk.
During the inspection, the Director of Nursing was unable to locate any policy or procedure governing the use and testing of exit door alarms and wander-guard systems, indicating gaps in the facility's written safety protocols.
The elopement incident and subsequent discovery of the malfunctioning alarm highlight the critical importance of functioning safety systems in facilities caring for cognitively impaired residents. When properly maintained and regularly tested, exit alarms provide immediate notification that allows staff to respond within seconds, potentially preventing injuries, deaths, or extended searches in dangerous environments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverbank Post-acute from 2024-06-05 including all violations, facility responses, and corrective action plans.
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