F0689

J

Failure to Supervise and Prevent Elopement of Two At-Risk Residents

Wood River, Illinois Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for two residents, both of whom had identified elopement risk and/or cognitive or psychiatric conditions. One resident (R2) had multiple diagnoses including dementia with agitation, schizophrenia, major depressive disorder, aphasia, chronic respiratory failure, facial weakness after stroke, and unsteadiness on feet. His MDS documented severe cognitive impairment and need for assistance with transfers and supervision or touching assistance for wheelchair mobility. R2’s care plans repeatedly identified him as high risk for elopement and falls, with interventions including use of a wander guard, monitoring of its function and placement every shift, replacement every 90 days, redirection from exits, and assistance with ADLs. Multiple elopement risk assessments over many months rated him as high risk.

On the night of his elopement, R2 exited through the front door around 2:05 AM in his wheelchair. Facility video and external agency camera footage showed him leaving the front lobby, moving toward a neighboring assisted living facility, remaining in that area for a period, then traveling along the road and out of camera view. Staff on duty did not identify him as missing until approximately 8:00 AM, despite expectations from leadership and multiple staff interviews that residents should be rounded on and visually seen at least every two hours to confirm safety. Night staff, including the assigned CNA and LPN, reported they did not lay eyes on R2 for extended periods, relied on verbal assurances rather than direct observation, and in one case mistook his roommate for him during rounds. Staff also reported they were not informed that R2 was at risk for elopement, were unaware of an elopement risk binder, and did not initiate a head count or elopement process when they could not locate him. R2 was ultimately located by police approximately 4.4 miles away from the facility in his wheelchair.

The report also documents systemic issues with the facility’s elopement prevention systems and door alarms. Although R2’s care plan required a wander guard, multiple medication administration notes in the weeks before and after the elopement documented that his wander guard was not in place or not available on several dates, and staff noted he frequently removed it. Leadership and staff gave conflicting accounts about whether R2 had a wander guard the night of the elopement and whether he was considered an elopement risk. The front lobby door alarm did not sound at the nurse’s stations like other exits, and several key staff, including the DON, HR, and RNC, were unaware that the front door alarm could not be heard from the nursing stations. The maintenance director confirmed that the front and north doors were set differently due to high traffic and that the front door alarm only sounded locally at the door. Staff interviews further showed inconsistent knowledge of elopement risk identification, reliance on residents knowing door codes, and lack of clear rounding policy at the time, all contributing to the failure to supervise and prevent R2’s elopement.

A second resident (R4) was also identified as at risk for elopement due to delusions and stated intent to leave, with care plan interventions including 1:1 as needed, 15–30 minute checks as needed, and use and monitoring of a wander guard. R4 eloped through the front door and was found across a busy two-lane road approximately 500 feet from the facility entrance. The report attributes both residents’ elopements to the facility’s failure to ensure the environment was free from accident hazards and to provide adequate supervision, including failure to consistently implement care-planned elopement interventions, failure to ensure functioning and properly monitored wander guards, and failure to maintain an effective door alarm system that alerted nursing staff when at-risk residents approached or exited through the front door.