F0689

J

Failure to Supervise High-Risk Dementia Resident 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 provide adequate supervision and prevent elopement for one cognitively impaired resident who was known to be at risk for wandering. The resident had diagnoses including unspecified dementia, psychosis, depression, and anxiety, and was consistently described as alert only to self, confused at baseline, and unable to care for herself. Quarterly MDS data showed she could ambulate 150 feet with supervision or touching assistance, and therapy notes documented that she could ambulate 275 feet without an assistive device. Progress notes and staff interviews described ongoing wandering behavior throughout the unit, frequent need for redirection for safety, and episodes of verbal and physical aggression during care. The resident’s psychiatric and primary care providers, as well as her representatives, characterized her as ambulatory, severely cognitively impaired, and unable to care for herself outside the facility.

Despite this history, the resident did not have an active electronic monitoring device at the time of the incident, even though prior physician orders and the active care plan documented use of such a device earlier in the year and identified her as an elopement risk. Elopement Risk Evaluations in February and May identified her as at risk, and her care plan included interventions related to elopement risk and monitoring of an electronic monitoring device. The DON later stated that the May Elopement Risk Assessment was incorrect because it was completed based on pre-hospitalization information, and the resident was not listed in the elopement binders as an elopement-risk resident on the date of the event. Facility leadership and nursing staff reported that when the resident returned from the hospital she was initially not an elopement risk due to being unable to get out of bed, and that when she later regained mobility and began walking well again, an electronic monitoring device was not reapplied because she was not considered exit seeking.

On the day of the incident, the resident was observed by staff on the fourth floor earlier in the shift, wandering as usual, and was redirected to her room. Approximately 10–15 minutes later, staff became aware that a door alarm was sounding from a stairwell exit on the west side or backside of the building, but they did not initially know why the alarm was going off or whether a resident had gone out. During this time, another cognitively intact resident, who was outside on a leave of absence, saw the confused resident walking around the west side of the building near generators, wearing a hospital gown and blanket, and appearing headed somewhere. He approached her, noted her confusion, and directed her to sit on a bench in front of the building, where a staff member saw them and helped bring her back inside. Staff interviews and the facility’s own investigation confirmed that no staff member observed the resident leaving the fourth floor, using the elevator or stairs, or exiting the building, and that staff did not know she had left the unit until she was brought to the front entrance by the other resident. The facility determined that she had exited through a stairwell door that should have been locked and that the alarm associated with that door could only be heard in or just outside the stairwell, not at the front reception area. This sequence of events, combined with the lack of an active electronic monitoring device and failure to recognize and manage her ongoing elopement risk, led to the resident’s unsupervised exit from the building and the determination of Immediate Jeopardy.

Resident representatives reported that the resident had "bounced back" and was up and moving weeks after her May hospitalization, and that she was always wandering, trying to escape, and attempting to get to doors and elevators. They stated that staff had told them multiple times that she tried to get out of the building and that she wandered in and out of other residents’ rooms, taking items. Clinical staff, including the OT, PMHNP, ARNP, and PCP, consistently described her as ambulatory, oriented only to person, confused, easily redirected, and not capable of caring for herself outside the facility, with some specifically stating they considered her an elopement risk. Nonetheless, she was not being monitored with an electronic device at the time of the event, and staff on the unit were unaware she had left the floor until after she had already been outside and was returned by another resident. These actions and inactions regarding risk assessment, care planning, and supervision directly contributed to the elopement event that formed the basis of the cited deficiency and Immediate Jeopardy determination.

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, completed an elopement assessment, and applied a wanderguard to her lower extremity; maintained 1:1 supervision until discharge.
• Completed wanderguard function and placement checks for all current residents at risk for elopement with no negative findings.
• Confirmed all residents’ demographics were included 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 and 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.
• Ensured Resident #5 was evaluated by psychiatric services and confirmed no injuries or complaints related to the event.
• Discharged Resident #5 to a memory care unit as planned with the IDT, family, and Medical Director.
• Placed a door guard at the door to ensure no one was able to leave the facility until additional alarm measures were installed.
• Completed elopement drills multiple times per day on random schedules.
• Completed weekly elopement drills on random days.
• Completed monthly elopement drills on random shifts and days and reviewed results with the QAPI team.
• Verified shipment of screamers 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 reached agreement.
• Completed a security company assessment 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 to review the ad hoc/QAPI plan with no negative findings and obtained Medical Director review with no recommended changes.
• Provided education to 100% of staff (including contract employees) related to abuse and neglect, missing persons policy, elopement policy (including care plans and KARDEX for those at risk for wandering/elopement), and staff response to door alarms.
• Initiated elopement drills for 100% of staff (including contracted employees).