F0689

J

Failure to Supervise Elopement Risk Resident Leads to Immediate Jeopardy

Jonesboro, Louisiana Survey Completed on 09-24-2025

Penalty

Fine: $12,740

Summary

A deficiency occurred when the facility failed to ensure adequate supervision and accident hazard prevention for a resident at risk for elopement. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and schizophrenia, was court committed to the facility and assessed as a wander/elopement risk. The care plan required visual checks of the resident's location every hour, diversional activities, and redirection as needed. Despite these interventions, the resident was able to exit the facility unsupervised by entering the code to a locked exit door, which he had obtained, and left the premises during the night.

The last staff observation of the resident occurred at 1:55 a.m., but the resident was not visually checked every hour as required by the care plan. Staff responsible for the resident's care admitted to not performing the required hourly monitoring due to being occupied with other residents. The resident was discovered missing only after being found by a maintenance supervisor at a gas station approximately five miles from the facility, having traversed a four-lane highway. The resident was returned to the facility by the local sheriff's office without injury.

Interviews with facility leadership and staff revealed they were unaware that the resident had access to the exit door code and that the required hourly visual checks were not being performed. The Director of Nursing and Assistant Director of Nursing confirmed that staff were not following the care plan interventions for monitoring the resident, and that there was a lack of awareness regarding the resident's ability to access secured exits. The failure to provide adequate supervision and to follow established protocols for a resident at risk for elopement resulted in an Immediate Jeopardy situation.

Removal Plan

• The ADON did a check for all admitted residents to establish a complete baseline.
• Resident #1 was placed 1:1 with staff upon return to the facility until departure.
• The ADON counseled all CNAs and Nurses for their lack of supervision of residents and excessive break time and provided all CNAs and Nurses with a disciplinary write up.
• The ADON and Maintenance Supervisor assessed all exit doors of the building to ensure they were locked and the codes were functioning properly. Codes to the exit doors were updated.
• The DON inserviced all CNAs and Nurses. At least one CNA must remain on the hall at all times for proper supervision of residents.
• The DON inserviced all CNAs and Nurses on importance of attentive supervision (every 2 hours rounding during assigned shift), as well as required rounding at each shift change to ensure all residents are safe and accounted for. All staff was inserviced prior to returning to work.
• The DON inserviced all staff that door code exits were changed and the new codes must not be given out to residents or visitors. Inservice also stated that any resident who wished to go outside must be supervised by staff. All staff was inserviced prior to returning to work.
• To verify understanding of all inservices an elopement questionnaire was developed and administered by DON and ADON and was completed by all nurses and CNAs. All staff inserviced prior to returning to work.
• All residents were reassessed by MDS and Clinical Care Coordinator (CCC) nurse for baseline to determine any other risk for elopement.
• All residents who require every 1 hour visualization are identified by a task on the computer, ordered on Medication Administration Record (MAR), signage above assigned bed, closet care plan and a list posted by the time clock.
• A construction company was notified by the Administrator that the fence needed improvements at the facility.
• A construction company repaired the fence.
• The DON or ADON will monitor camera footage at random to ensure that CNAs and nurses are not taking excessive break times and that at least one CNA remains on each hall at all times. This monitor will be completed at random and any noncompliance will be addressed.
• The CNAs and LPNs will rotate every 2 hour rounds through the facility so that all residents have a visual check every 1 hour by staff. CNAs will round on odd hours and nurses will round on even hours. These forms will be turned into the DON and ADON to ensure that this implementation is being followed. Rounding will be completed every 1 hour on all residents and will continue on all residents who have a every 1 hour monitor order but may continue until compliance is met.
• Residents identified for every 1 hour monitoring are identified by signage above their bed, listed on closet care plan, order in Kiosk for CNAs, order in the computer for nurses, as well as a list by the time clock. Any noncompliance will be addressed.
• The DON and ADON will visualize rounds with CNAs and LPNs at random times throughout the week to ensure compliance either by in person or reviewing camera footage. This monitor will be completed at random but may continue weekly until compliance is reached. Any noncompliance will be addressed.
• An Elopement Questionnaire will be completed with 2 CNAs and 1 nurse at random by the DON or ADON. Any noncompliance will be addressed.