F0689

J

Failure to Supervise and Implement Elopement Interventions for High-Risk Resident

Monmouth, Illinois Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and implement interventions for a resident with a known history of elopement and exit-seeking behaviors, resulting in an elopement event. The facility’s Wandering & Elopement Assessment and Prevention policy requires all residents to be assessed for elopement/unsafe wandering and defines elopement as a resident unable to protect themself who departs the facility or enters a non-resident area unsupervised or undetected. The resident was admitted in February 2023 and had documented elopement risk on assessments dated 9/7/23 and 4/3/25, including a history of leaving the facility and exhibiting exit-seeking behaviors. The care plan documented Alzheimer’s/dementia, poor safety awareness, fall risk, and the need for staff supervision when ambulating with a walker.

Despite this known history, the resident did not have a wander guard in place prior to the elopement event, and the administrator later stated that the resident had refused a wander guard, but this refusal was not documented. The administrator confirmed the resident had previously eloped in September 2023 and was found walking on a street, and the resident’s friend reported another prior elopement shortly after admission when the resident left to go to a parade and was found walking on a busy street. On the date of the cited elopement, multiple CNAs reported seeing the resident ambulating in the hallway with a walker shortly before staff realized the resident was missing. Staff then searched the facility and perimeter, and the administrator drove offsite and found the resident at a local coffee shop two blocks away, where EMS had responded after a concerned citizen called 911 upon seeing the resident walking with a walker.

The facility also failed to document the elopement event in the resident’s electronic medical record, despite the policy requirement that an incident report be completed noting investigative procedures, witness statements, and pertinent information. The DON stated she was made aware that staff were looking for the resident and joined the search, and later acknowledged there was no documentation in the chart regarding the elopement and that such documentation should have been present. A nurse progress note dated two days after the event documented that the resident remained on 15-minute checks for safety and observation after a recent exit-seeking episode, but there was no progress note or assessment specifically addressing the elopement that occurred. These actions and omissions led surveyors to determine that the facility failed to ensure adequate supervision and implementation of interventions to prevent elopement for a resident at known risk.

Removal Plan

• In-service all staff members on the elopement policy and procedure.
• In-service all remaining staff members via telephone prior to their next shift on the elopement policy and procedure.
• Conduct an audit of medical charts to ensure interventions are in place and documentation of the event with all actions taken is recorded.
• In-service all nurses on incident charting and completion.
• Complete updated wandering/elopement assessments for all residents.
• Review care plans for accuracy.