F0689

D

Failure to Prevent Elopement and Maintain Accurate Elopement Risk Management

Lake Bluff, Illinois Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent an elopement from a locked unit, to maintain an accurate list of residents at risk for elopement, and to update a resident’s care plan after an elopement. A resident with diagnoses of schizophrenia, anxiety, and depression was admitted to the facility and had documented delusions, paranoia, irritability, and a stated desire to leave the nursing home. A hospital history and physical noted that the resident had previously tried to leave the nursing home to go to the store, and a social service note described the resident as ambulatory, aggressive with threats and gestures for several hours, and considered at high risk for leaving the facility unattended. An elopement risk evaluation dated 12/2/25 identified the resident as at risk for elopement, and the care plan documented the resident as an elopement risk/wanderer with interventions such as disguising exits and providing diversions.

On the day of the elopement, staff interviews and documentation showed that the resident was brought from the locked second floor to the first floor for a smoke break by a CNA, along with another resident. When it was discovered that neither resident had cigarettes, the CNA returned both residents to the second floor and then continued caring for other residents. Shortly thereafter, the receptionist reported that the resident arrived alone at the reception area on the first floor and requested a cigarette. The receptionist paged second-floor staff to come get the resident, but the resident exited the building through the front door before staff arrived. Maintenance staff and an administrative assistant pursued the resident; maintenance staff caught up with the resident beyond the facility parking lot near a stop sign and continued walking with the resident until police arrived further away from the facility.

The facility’s locked second floor required a fob to operate the elevator, and nursing staff and administration stated that residents on this unit should not be able to exit without staff assistance and that a staff member should be present at the nurse’s station at all times to monitor the elevator. Multiple staff, including the RN working on the second floor, the CNA, the LPN, and the assistant DON, stated they did not know how the resident got to the first floor unaccompanied. The psychiatric NP reported that she had been walking and talking with the resident near the elevator on the second floor and then used a nurse’s fob to access the elevator to go to another floor, leaving the resident in the common area near the elevator. At the time of survey, the facility’s elopement risk list, kept in a binder, had last been updated on 11/19/25 and did not include this resident despite the documented elopement risk; the LPN added the resident’s name during the survey. The resident’s care plan, printed on 1/5/26, showed elopement risk interventions initiated on 12/2/25, but no additional interventions were added after the elopement on 12/12/25, and staff confirmed that the care plan had not been updated following the incident.