F0600

J

Failure to Prevent Resident Elopement Due to Inadequate Supervision and Security

West Palm Beach, Florida Survey Completed on 09-05-2025

Penalty

No penalty information released

Summary

A deficiency occurred when the facility failed to protect a resident from neglect by not providing necessary supervision to prevent elopement. The resident, who had a history of Parkinson's Disease, cognitive impairment, and other significant medical conditions, was identified as being at risk for elopement and resided in a secured unit. Despite this, the resident was able to exit the facility undetected through the main entrance while the receptionist was distracted by visitors. The main entrance required manual unlocking after a buzzer was engaged, and the receptionist, responsible for monitoring the entrance camera, did not notice the resident leaving. There were no additional staff present at the entrance at the time of the incident.

The resident's care plan and medical orders clearly indicated an elopement risk, and she was supposed to be provided with safe wandering interventions and supervision. On the day of the incident, the resident was last seen in the dining room and then was not found during medication pass and dinner. Staff initiated a search after realizing the resident was missing, but by that time, the resident had already left the building. The facility's layout allowed access from the secured unit to the main lobby and entrance through unsecured hallways, and the entrance system allowed visitors to enter without a code, though a code was required to exit. This system was in place at the time of the incident, and staff interviews confirmed that visitors could access the secured unit without a code, potentially allowing residents to leave unnoticed.

The resident was found by law enforcement several hours later, approximately two miles from the facility, with minor injuries such as abrasions and bruising. She missed several doses of her prescribed medications during the period she was missing. Interviews with staff indicated that the resident had not previously exhibited exit-seeking behaviors and that staff were not aware of any immediate risk on the day of the incident. The failure to provide adequate supervision and effective security measures directly led to the resident's elopement and the resulting deficiency.

Removal Plan

• 100% headcount of residents was completed to ensure no other residents were missing. All other residents were accounted for.
• A whole house search of the facility was completed.
• The executive director was notified by the weekend supervisor who in turn notified facility managers to report to work to assist in the search. Regional and divisional staff were also notified and reported to the facility to assist in the search. The medical director and primary physician were notified.
• An external search of the community was initiated.
• Executive Director notified the local Police Department who assisted in the search.
• Upon return, the resident was placed on one-to-one supervision on the secured unit. (1:1 monitoring ordered).
• All facility exit door alarms and screamer devices were inspected by the Maintenance Director.
• Keypad code to secure unit was changed by the Maintenance Director.
• Immediate education on abuse neglect and exploitation and risk of elopement initiated.
• 3-11 shift sign-in sheet reviewed. 11-7 signage sheet reviewed. No concerns.
• The elopement risk assessments of all residents were reviewed for accuracy.
• An elopement drill was performed for the 11-7 shift.
• The resident was assessed by the nurse upon return and by the physician. Skin assessment done.
• An elopement drill was performed for the 7-3 shift.
• The care plans and kardexes of residents at risk for elopement were reviewed for accuracy.
• Visitor lanyards were ordered for identification of visitors/vendors to differentiate visitors from residents. The lanyards were put into use immediately.
• Keypad order to replace push button for entry to units. Keypad was installed.
• Elopement books were reviewed for accuracy.
• An ad hoc QAPI was performed by the facility IDT and reviewed by the Medical Director.
• The Executive Director initiated education related to abuse/neglect reporting.
• The Assistant Executive Director notified the Department of Children and Families of the elopement of Resident #1.
• A Federal Immediate Report was submitted.
• Current facility staff were provided education by the Director of Nursing and Assistant Director of Nursing pertaining to what constitutes resident mistreatment, abuse, neglect, and misappropriation of resident property. Any employees who have not received the training were notified they must receive the training prior to working their next scheduled shift. New employees hired after will receive education during the facility orientation process. Education pertaining to abuse/neglect is provided annually and as needed.
• Facility practices which assist in monitoring/identifying potential abuse and neglect include, but are not limited to: grievance process, complaints resolution process, facility theft and loss reporting, resident council, incident reporting, internal audits of resident trust accounts, daily staffing practices, and regular direct indirect supervision of nursing home employees and resident care by supervisory and administrative staff.
• Root cause analysis was performed by the regional director of clinical services related to the circumstances of the resident elopement. An IDT review and investigation of the residence episode of elopement was completed through the ad hoc copy process. Included in the investigation was reviewed the residence condition preadmission and post admission, resident evaluations including the accuracy of elopement evaluation resident care plan, staffing, facility environments and equipment.
• The residency elopement risk evaluation was completed accurately at the time of admission and a care plan for elopement risk was initiated. The resident was correctly placed on the locked [NAME] wing unit at the time of admission.
• The staffing PPD for licensed nurse assist and for CNA's. On the [NAME] Wing units on the 3:00 PM to 11:00 PM shift, there were two nurses and five CNA's for the 52 residents. 2 weeks staffing calculations (State only Requirement) reviewed with no concerns.
• Staff who predominantly work on the [NAME] Wing were interviewed via a questionnaire and asked if the resident displayed any exit seeking behaviors prior to the incident, verbalizations of wanting to leave, packing belongings, or pushing on exit doors. The staff report no indications of such desire to exit or knowledge of any exit seeking behavior.
• The investigation and root cause analysis revealed potential root cause scenarios (birthday party and push button entrance).
• Elopement risk evaluation facility systems processes in place related to patient identification of potential for elopement/ wandering and safety in place and followed.
• The elopement risk evaluation is completed on admission, quarterly, and after a significant change period the evaluation consists of ambulatory mobility status, wandering behaviors, cognitive status, and exit seeking indicators.
• If a patient is identified as a potential risk, based upon the evaluation, a patient identification form, which will include a current photo, a current description, and personalized care plans, and interventions, and redirection strategies. The patient elopement book contains copy of the patient identification form, a colored photo of the patient and a face sheet. The elopement books are maintained at each nursing station and at the entrance to the reception facility area.
• Facility door prevention maintenance, monitoring and checked for function weekly conducted as scheduled.
• All exit doors are inspected weekly.
• All designated entrance/exit areas have scheduled staff assigned to the receptionist area from 8:00 AM to 8:00 PM seven days a week.
• Staffing schedules are monitored daily by staffing coordinator and reviewed with executive director of nursing and or nursing supervisor on duty to ensure adequate staffing is maintained. Adequate staffing means all minimum PPD, and ratios are met and in addition, staffing is adjusted based on acuity of patient needs.
• All staff are screened prior to hire and a job specific orientation is performed. Receptionist not only receive training but have a completed competency on file.
• A review of five receptionist staff employees' file revealed all had completed training and had a competency on file. The receptionist on duty at the time of the residence elopement was suspended immediately and has subsequently been terminated.
• The maintenance staff performed an inspection of the facility exit doors and screamer devices and all were found to be fully functional.
• Weekly door checks by the Maintenance Director will be performed to ensure proper function. The push button entry system onto the memory care unit was replaced with the keypad the truth device.
• Facility licensed nurses completed a review of the accuracy of 185 current residents elopement risk evaluations. Of the 185 residents, 52 residents resided in the memory care unit and 51 of those who were already assessed to be at risk for elopement. The remaining 1 of 52 residents was originally placed on The [NAME] Wing unit for behavior management but has since become a risk for elopement. The residence assessment was updated to reflect the risk of elopement.
• The care plans and CNA Kardexs' of 52 of 52 residents at risk for elopement were reviewed. All were found to be in compliance with risk for elopement identified.
• Director of Nursing /designee to complete monitoring of new admission evaluations to ensure risk for elopement is accurately identified and care plan and Kardex are reflective of the risk, where appropriate.
• The Medical Director was informed of the citations and is in agreement with the removal plan.