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F0689
J

Failure to Secure Exit Doors and Complete Resident Monitoring Leads to Elopement

Hannibal, Missouri Survey Completed on 04-04-2025

Penalty

Fine: $25,500
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident identified as at risk for elopement, with a history of cognitive impairment, mental illness, and previous wandering activity, was able to leave the facility without staff knowledge. The resident exited through interior, alarmed, coded double doors from the dining room to the front entrance, and then through the front entrance doors, neither of which had their alarms activated or secured at the time. The resident walked approximately one mile, crossing multiple lanes of traffic, and eventually fell by the roadside before being assisted by a passerby and returned to the facility by police. Staff failed to complete required face checks every two hours, as documented in the electronic charting system, with missed checks at midnight and 2:00 A.M. The resident was not discovered missing until 2:45 A.M., resulting in the resident being out of the facility for approximately four hours. Interviews revealed that staff were aware of the need for face checks and door security, but these procedures were not followed on the night of the incident. Additionally, the resident's care plan and elopement risk documentation were not updated to reflect current interventions or monitoring requirements, and the resident was not included in the facility's elopement risk book at the nurses' desk. Observations confirmed that the alarm systems on both the interior and exterior doors were not properly activated, allowing the resident to exit undetected. The facility's elopement policy required immediate action and staff training, but there was no written policy regarding the frequency of face checks or securing entrance doors at night. The resident, who was independently mobile and had a diagnosis of schizophrenia, was able to leave the facility and was found with a skin tear after the incident.

Removal Plan

  • In-service education was provided for all facility staff including updated elopement policies, face check policies and door monitoring policies.
  • Staff completed elopement risk assessments for all residents.
  • The elopement risk and code white procedure books were updated with current risk assessments and code white procedures.
See complete original report
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