F0600

J

Failure to Supervise High-Risk Wanderer Resulting in Unnoticed Elopement

Tampa, Florida Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from neglect related to elopement. A cognitively impaired resident with dementia, severe disorientation, and a history of wandering exited the building from the fourth floor to the outside, unnoticed by staff. The resident was ambulatory, able to walk significant distances independently with a steady gait, and had documented wandering behaviors, including going into other residents’ rooms and requiring frequent redirection for safety. Despite these characteristics and prior identification as an elopement risk on risk evaluations, the resident did not have an active electronic monitoring device in place at the time of the incident.

The resident’s records showed that she had previously been identified as an elopement risk and had an elopement-focused care plan that included use of an electronic monitoring device and monitoring of that device for function. Physician orders for checking the electronic monitoring device each shift had been in place earlier in the year but had ended months before the elopement. The care plan, however, still reflected interventions related to an electronic monitoring device. Staff interviews revealed that the resident typically wandered on the fourth floor, was easily redirected, and had not been seen off the unit before. Multiple clinical providers, including the primary care provider, ARNP, PMHNP, and therapy staff, described the resident as ambulatory, oriented only to person, unable to care for herself, and at risk for following others toward exits or elevators.

On the day of the incident, staff on the unit saw the resident around change of shift and redirected her to her room, but they were unaware that she had left the floor and the building. An alarm sounded from a stairwell exit door on the lower level, but staff did not initially know why it was sounding or whether a resident had gone out. Another cognitively intact resident, who was outside on a leave of absence, observed the confused resident walking around the west side of the building in a hospital gown and blanket, approached her, and brought her to sit on a bench at the front of the building, where a staff member then saw them and assisted the resident back inside. Facility leadership and staff were unable to determine how the resident traveled from the fourth floor to the first floor or how she accessed a stairwell door that should have been locked with a keypad. The facility’s own abuse/neglect policy defined neglect to include failure to adequately supervise a resident known to wander from the facility without staff knowledge, and the surveyors determined that this failure resulted in a situation that created a likelihood for serious injury or death and constituted Immediate Jeopardy.

Interviews with the NHA and DON indicated that the resident had initially been considered an elopement risk earlier in the year, then was viewed as not at risk after a hospital stay when she was non-ambulatory. They acknowledged that an Elopement Risk Assessment completed in May was incorrect because it was based on pre-hospital information, and that the resident was not listed in the elopement binders at the time of the incident. They also confirmed that although the resident’s mobility improved and she began walking well again and wandering, an electronic monitoring device was not reapplied because she was not perceived as exit seeking. Resident representatives reported that the resident had “bounced back” after her decline, was always wandering, tried to get to doors and elevators, and had been described by staff as trying to get out of the building. These documented conditions, combined with the absence of an active monitoring device and the lack of staff awareness of her departure from the unit and building, led to the neglect finding related to elopement.

Removal Plan

• Returned Resident #5 to the facility.
• Completed a skin assessment, pain assessment, and change of condition assessment for Resident #5 with no negative findings.
• Notified Resident #5’s attending physician and obtained new orders for labs; obtained urine culture results showing ESBL and implemented new medication orders.
• Completed psychiatric services via telehealth for Resident #5 with no new orders received.
• Placed Resident #5 on 1:1 supervision and completed an elopement assessment with an electronic monitoring device applied to her lower extremity; maintained 1:1 supervision until discharge.
• Checked electronic monitoring device function and placement for all current residents at risk for elopement with no negative findings.
• Verified all residents’ demographics were in each resident elopement binder at the nurse station, receptionist area, and therapy gym.
• Added Resident #5’s demographics and picture to the elopement binder.
• Completed door checks to ensure all doors worked properly with no negative findings.
• Completed a 100% head count to ensure all residents were in the facility with no negative findings.
• Re-assessed 100% of residents for elopement risk with no new residents identified.
• Completed an elopement drill; reviewed and documented results on the Elopement Drill QAPI worksheet with no negative findings.
• Gathered witness statements from residents and staff.
• Notified DCF and police of an allegation of neglect.
• Arranged for psychiatric services evaluation for Resident #5.
• Discharged Resident #5 to a memory care unit as planned with the IDT, family, and Medical Director.
• Placed a door guard to ensure no one was able to leave the facility until screamers were installed.
• Completed elopement drills every day, three times per day, randomly.
• Completed elopement drills once per week on random days.
• Completed monthly elopement drills on random shifts and days, with results reviewed with the QAPI team.
• Verified screamers were shipped from the manufacturing company.
• Installed cameras and new secure care boxes.
• Completed door checks to ensure doors were functioning properly.
• Met with the IDT and Clinical Consultant to discuss removal of the door guard and removed it.
• Assessed for a possible amber alarm system and installed the system.
• Set up security cameras in the facility with the main station located in the NHA office.
• Held IDT meetings (including the Medical Director) to review the ad hoc/QAPI plan; the Medical Director reviewed and recommended no changes.
• Provided education to 100% of staff (including contract employees) regarding abuse/neglect, missing persons policy, elopement policy (including care plans and Kardex for those at risk), and staff response to door alarms.
• Initiated elopement drills for 100% of staff (including contracted employees).