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F0689
L

Failure to Systematically Assess and Monitor Resident with Exit-Seeking Behaviors Leads to Elopement

Highland, Illinois Survey Completed on 09-04-2025

Penalty

No penalty information released
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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

The facility failed to implement a systematic approach to assess and monitor a resident with known unsafe wandering and exit-seeking behaviors, resulting in multiple elopement incidents. One resident with diagnoses of dementia, anxiety disorder, and depression, who was severely cognitively impaired and required substantial assistance, was not consistently identified as at risk for elopement in assessments, despite documented exit-seeking behaviors and previous elopement attempts. The care plan noted interventions such as redirection and 15-minute checks, but there was a lack of consistent documentation and follow-through, and the resident was able to leave the facility unsupervised on more than one occasion. Staff interviews revealed that there was no centralized or accessible list or binder of residents at risk for elopement, and many staff members were unaware of which residents were at risk or what interventions were in place. Several staff, including CNAs, LPNs, and RNs, stated that they relied on shift reports or visible Wander Guard devices to identify at-risk residents, but there was no formal system for tracking or communicating this information. Additionally, staff were not always aware of the resident's medical history or cognitive status, and there was confusion and lack of documentation regarding elopement incidents, with some staff and administrators denying that elopements had occurred or failing to complete incident reports as required by facility policy. Observations and interviews with staff, residents, and local police confirmed that the resident was able to exit the facility through both the front and fire exit doors without staff supervision, and in one instance, was found by police outside the facility. The lack of a systematic approach to assessment, documentation, and monitoring of residents with exit-seeking behaviors, as well as the absence of clear communication and staff awareness, directly contributed to the resident's ability to elope and the facility's failure to prevent these incidents.

Removal Plan

  • Care plan reviewed to ensure appropriate interventions addressing exit-seeking behaviors.
  • Elopement risk assessment reviewed for accuracy and completeness.
  • Elopement assessments for all residents were reviewed and updated for accuracy as needed.
  • Care plans for residents identified as at risk for elopement were reviewed and revised with appropriate interventions.
  • Behavior tracking was initiated for all residents identified as at risk for elopement or exit-seeking behaviors.
  • Staff education on elopement policy and procedures, recognition of exit-seeking behaviors, accurate and timely documentation requirements, and location/use of the facility's Elopement Binder.
  • Licensed nursing staff received additional targeted training on documenting elopement attempts and exit-seeking behaviors.
  • Facility will ensure staff members are educated prior to working their next shift if unable to be reached initially.
  • Elopement Policy and Documentation Policy regarding exit-seeking behaviors were reviewed and approved by Chief Nursing Officer and Chief Operating Officer.
  • DON or designee will review the 24-hour report and behavior tracking logs to identify and address exit-seeking behaviors.
  • DON or designee will review all new admissions and readmissions to ensure elopement assessments are accurate and care plans reflect appropriate interventions.
  • Administrator or designee will provide in-services on elopement policy, identification of exit-seeking behaviors, and implementation of appropriate interventions.
  • Administrator or designee will conduct monitoring of three residents identified as at risk for elopement to ensure elopement assessments are completed, wandering/exit-seeking behaviors are documented and addressed with interventions, and care plans are updated as needed.
  • Results of all monitoring activities will be reviewed during QAPI meetings led by the Administrator.
  • Additional education and corrective measures will be implemented as necessary until sustained compliance is achieved.
See complete original report
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