F0656

J

Failure to Implement Elopement Care Plan and Supervision on Secured Unit

Louisville, Kentucky Survey Completed on 12-14-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident assessed as being at risk for elopement. The resident was admitted with dementia with behavioral disturbance, cognitive communication deficit, anxiety, and major depressive disorder, and was placed on a secured memory care unit for safety. An Elopement/Wandering Risk Evaluation identified the resident as a moderate elopement risk, and the comprehensive care plan required that the resident reside on the secured unit with supervision while on the unit. The care plan also included diversion and structured activity interventions such as toileting, walking inside and outside, reorientation strategies with signs and pictures, and use of memory boxes.

In the days leading up to the incident, progress notes documented that the resident repeatedly expressed a desire to go home. On the night of the elopement, an alarm sounded on the women’s memory care unit exit door. Staff interviews revealed that CNAs and the LPN on duty were occupied providing showers and care to other residents when the alarm went off. One CNA reported seeing the resident at the exit door and moving her to the dining room but did not know the code to stop the alarm and sought assistance from the LPN. The LPN reported checking the courtyard, stepping outside, and checking resident rooms after the alarm, but staff did not identify that the resident was missing at that time. Another CNA stated that after the alarm was silenced, she returned to showering residents and later noticed the unit was unusually quiet, as the resident was typically loud, but no one was actively looking for the resident.

The resident ultimately left the facility unsupervised and without staff knowledge, later being found by citizens in a local park who contacted law enforcement. The sheriff’s officer reported that when he first arrived at the facility and asked staff if the resident was missing, staff stated she was in her room; only after checking the room did they realize she was gone. The resident told the officer and bystanders that she had been held captive and had run away, and she told surveyors she had prayed for an intervention, that both exit doors opened, and that she escaped through a faulty fence slat and ran to the park. She also stated she was very unhappy, did not feel she belonged at the facility, and would leave again if able. Staff interviews confirmed that the care plan interventions requiring supervision on the secured unit and provision of diversional, person-centered activities were not implemented at the time of the elopement because staff were engaged in care of other residents and some staff were unfamiliar with the unit and its procedures.

Removal Plan

• Updated Resident 1 care plan to include increased supervision by staff, implemented q15-minute checks immediately, and completed psychosocial visit/assessment once daily for 3 days
• Completed pain evaluation for Resident 1 (no negative findings)
• Conducted medication and laboratory reviews for Resident 1
• Conducted elopement drills by Maintenance Director to ensure staff comprehension; staff verbally validated understanding
• Completed 100% elopement evaluations on all facility residents by licensed nursing staff
• Reviewed 100% of elopement care plans by MOS Coordinator and Director of Nursing Services
• Completed 100% staff education (including contract staff) on the Elopement policy and procedure by Executive Director, Director of Nursing Services, and department heads; staff verbally validated understanding
• Completed education for Social Services staff and MDS Coordinator on updating resident care plans and implementing interventions; staff verbally validated understanding
• Reviewed all residents’ care plans to ensure elopement risk is reflected on the comprehensive care plan and Kardex
• Implemented requirement that all residents who trigger for 'at-risk' and 'high-risk' will have an elopement care plan
• Revised resident care plans to include residents at risk for elopement
• Reviewed the Elopement Policy by the IDT to include individualized interventions for residents at risk for elopement
• Implemented weekly audits of new admissions for 3 months to ensure elopement risk and interventions are in place and care plan/Kardex updated
• Provided education to nursing staff on updating care plans, elopement evaluation, and Kardex as needed
• Continued staff education plan until complete; no staff (including new hires/contract) may work until educated; staff verbally validated understanding
• Completed elopement risk assessments on all residents by Director of Nursing Services/MOS Coordinator/Therapy Director
• Educated MOS/Social Services on elopement evaluation and implementing individualized interventions (supervision/observation), completing evaluations, following care plan/Kardex, and responding to alarms; staff verbally validated understanding
• Educated 100% of staff on revising care plans after identifying at-risk residents, individualized supervision/observation interventions, completing evaluations, following care plan/Kardex
• MOS Coordinator reviewed all baseline and comprehensive care plans to ensure revisions after identification of at-risk residents per elopement evaluations
• MOS Coordinator reviewed all comprehensive care plans to ensure revisions after identification of at-risk residents per elopement evaluations
• Held an ad-hoc QAPI meeting with leadership/IDT to review the plan and findings
• Forwarded Care Plan and Elopement Assessment audits to the Executive Director for QAPI Committee review monthly for at least 3 months to ensure ongoing compliance
• Held QAPI meetings monthly
• Audited and reviewed all monitoring by Executive Director and/or Director of Nursing Services until ongoing compliance is achieved; corrected deficient practices immediately and referred to QAPI Committee for further review and interventions