Munson Healthcare Crawford Continuing Care Center

alarm was not sounding despite the open door. CNA E stated she did not observe anybody engaging the silence button as she walked by the nurses' station with R1.

When asked if CNA E notified staff about the malfunctioning alarm, she stated she did not because her priority at the time was to ensure R1 was assisted with toileting needs and acclimated to her room and the facility. CNA E stated R1 became restless and somewhat agitated as the day progressed, wandering in and out of resident rooms and walking around the facility. CNA E recalled the nursing assistants started taking their afternoon breaks around 3:15 PM and stated she could not locate R1 upon her return around 3:45 PM - 4:00 PM. On 8/19/25 at 1:50 PM, an interview was conducted with Maintenance Worker (MW) I who confirmed the exit door alarm would continue to sound while open unless the reset button was continuously held. MW I further explained after the door is opened and shuts, the reset button must be pushed once to disengage the alarm.On 8/19/25 at 12:26 PM, a telephone interview was conducted with Registered Nurse (RN) C regarding the elopement event on 8/1/25. RN C recalled soon after R1 arrived at the facility, she appeared restless and began wandering in and out of other resident rooms. RN C stated she placed a WanderGuard (an electronic monitoring system used to prevent at-risk residents from leaving designated safe areas by triggering an automated alarm when the user nears a restricted exit). RN C stated she was notified by CNA E that R1 could not be located and began a facility search around 4:00 PM (38 minutes after R1 was observed exiting the facility via security footage). RN C stated, I am 100% positive I didn't hear a [door] alarm go off.On 8/19/25 at 1:12 PM, an interview was conducted with OT H who confirmed she had located R1 in an elementary school parking lot following the elopement incident on 8/1/25. OT H stated she was assigned to look for R1 in Parking Lot A which was in front of the attached hospitals' emergency department. OT H walked the elopement path with this surveyor and recalled she had looked across a side street and saw a person, eventually identified as R1, sitting on top of stairs leading to a stationed construction trailer in a parking lot. OT H confirmed R1 must have independently crossed the busy side street which served as the main entrance and exit for hospital employees as well as emergency vehicles. OT H stated she did not hear a door alarm prior to the elopement event.On 8/19/25 at 12:13 PM, an interview was conducted with CNA D who stated she was working at the time of the elopement and did not hear a door alarm prior to R1's exit.On 8/20/25 at approximately 9:20 AM, an interview was conducted with the NHA who stated the facility was unable to determine if R1's elopement occurred because of a door alarm malfunction or if a facility member silenced the alarm without conducting a visual search of the area.

The NHA understood the concern regarding the extended period of time which elapsed prior to the initial elopement detection as well as the lack of post-incident documentation in accordance with facility standards.

Review of the facility policy titled, Missing Resident/Elopement Policy, revised 9/12/24, read, in part: Purpose: Maintain the safety and security of our residents.

All staff members within this facility are responsible for maintaining the safety of all residents.

Documentation of the Wandering resident must include the following. A Risk Watch report must be filled out.

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