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F0689
J

Failure to Prevent Elopement and Provide Adequate Supervision

Saint Charles, Missouri Survey Completed on 04-24-2025

Penalty

Fine: $26,130
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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 with a history of schizophrenia, bipolar disorder, Alzheimer's disease, and vascular dementia, who was assessed as being at risk for wandering and elopement, exited the facility through an alarmed fire exit door without staff knowledge. The resident was ambulatory with a wheelchair, had a severely impaired cognition, and had recently exhibited aggressive behavior, resulting in an order for 15-minute checks. However, staff failed to complete and document the required 15-minute checks during the relevant time period. The door alarm intended to alert staff to unauthorized exits was not loud enough to be heard until staff were already partway down the hall, as confirmed by multiple staff and resident interviews. Neither the resident's roommate nor another resident on the same hall heard the alarm, and staff only became aware of the resident's absence when a call light was noticed and the resident was found missing from their room. The resident's wheelchair was found by the exit door, and the alarm was only heard after staff began searching for the resident. The resident was later found outside the facility by a local citizen, having sustained multiple serious injuries including facial fractures and a subdural hemorrhage. The timeline and interviews indicate that the lack of timely supervision, failure to perform required checks, and insufficient alarm volume contributed to the resident's unsupervised exit and subsequent injury.

Removal Plan

  • Conduct an investigation and notify appropriate parties including the police.
  • Provide in-service education for all facility staff including elopement policies, check policies and door monitoring policies.
  • Complete elopement risk assessments for all residents.
  • Update the elopement risk and code white procedure books with current risk assessments and code white procedures.
  • Adjust alarmed, fire, exit door alarms to increase the volume of the alarm for staff to recognize the alarm promptly.
  • Perform alarmed door audits and check audits and continue ongoing audits.
See complete original report
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