F0689

J

Failure to Supervise Exit-Seeking Resident Leads to Elopement from Secure Memory Unit

Louisville, Kentucky Survey Completed on 12-14-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe, secure environment for a cognitively impaired resident on a memory care unit, resulting in an elopement. The resident was admitted with dementia with behavioral disturbance, cognitive communication deficit, anxiety, and major depressive disorder, and hospital records indicated the need for a secured, locked unit due to impaired safety decisions and poor safety awareness. On admission, the facility’s elopement/wandering risk evaluation scored the resident as a moderate elopement risk, and the admission MDS showed a BIMS score of five, indicating severe cognitive impairment. The resident’s care plan, initiated shortly after admission and later revised, included goals and interventions to maintain safety on the secure unit, including supervision while on the unit and provision of activities of interest with redirection as needed.

In the days leading up to the incident, progress notes documented escalating behaviors and clear exit-seeking. Notes from several days before the elopement described the resident as having behavioral issues, constantly stating a desire to go home, yelling out for God to get her out, and repeatedly expressing a desire to leave. Staff interviews further confirmed that the resident frequently packed a suitcase, made statements about wanting to go home, pushed on exit doors, and watched the doors to see if someone would go out. On the day of the elopement, staff reported the resident was antsy, wanted to get out, and was not redirectable, with social services noting that the resident insisted she needed to get to her dying mother. Despite these known behaviors and documented risks, the resident was placed in a room directly catty-corner to an exit door on the secure unit, and there is no indication in the report that enhanced supervision such as 1:1 monitoring was consistently implemented at the time of the incident.

On the evening of the elopement, staff on the women’s memory care unit consisted of one LPN and two CNAs for 16 residents, and all three staff members reported being occupied with other resident care tasks when the alarm sounded. One CNA reported hearing the alarm, going to the exit door, seeing another resident in a wheelchair, moving that resident, and, along with the LPN and another CNA, checking the courtyard and not seeing anyone before the LPN turned off the alarm. Another CNA stated she saw the eloping resident at the exit door when the alarm went off, moved her to the dining room, and then returned to provide a shower to another resident, noting that the door did not lock right away and that no one was actively looking for the resident later. The LPN reported responding from the men’s secure unit when the alarm sounded, checking the courtyard and resident rooms per policy, and stated he did not realize the resident was missing until a law enforcement officer arrived and asked about her.

The resident was able to exit the building through the alarmed exit door and then leave the courtyard through a deteriorated wooden gate connected to the privacy fence. The maintenance director later acknowledged that the gate’s wood boards were beginning to deteriorate before the incident and that the resident was able to push through the boards and then place them back, securing the gate with empty plant pots on the opposite side, which led staff to believe the gate was secure when checked. The resident reported that on the night she left, both exit doors near her room opened, that the wood gate was faulty and allowed her to get through, and that she ran to a nearby park where she sat on a bench and told a couple about her escape. Concerned citizens at the park called 911, and a sheriff’s officer responded, found the resident, and then went to the facility, where staff initially stated the resident was in her room and were unaware she had left until they checked and found her missing. The officer reported that no staff member told him they were looking for or missing a resident, and the resident herself stated she was unhappy in the facility, did not feel she belonged there, and would leave again if able.

The facility’s own elopement and wandering policy stated that residents at risk for elopement were to receive adequate supervision to prevent accidents, that alarms were not a replacement for necessary supervision, and that staff were to respond to alarms in a timely manner. The policy also required a systematic approach to monitoring and managing residents at risk for elopement, including identification and assessment of risk, implementation of interventions to reduce hazards and risks, and monitoring and modifying interventions as needed, with interventions added to the care plan and communicated to appropriate staff. Despite this, staff interviews revealed that at the time of the elopement, all assigned staff were engaged in other resident care tasks, could not provide supervision or diversional activities as outlined in the care plan, and did not recognize or report the resident as missing until notified by law enforcement. The combination of the resident’s known exit-seeking behavior, placement in a room adjacent to an exit door, a defective courtyard gate, and staff being occupied with other tasks when the alarm sounded led to the resident leaving the secure unit and the facility without staff awareness, resulting in the identified deficiency under F689 for failure to ensure adequate supervision and a hazard-free environment.

Removal Plan

• Conduct elopement drills once per shift to ensure staff comprehension of the elopement drill process.
• Complete a 100% audit of door and lock evaluations with no negative findings.
• Complete 100% elopement evaluations.
• Provide 100% staff education (including contract staff) on the Elopement policy/procedure and appropriate resident supervision.
• Initiate an investigation of the incident, including staff interviews and a root cause analysis.
• Repair the defective courtyard gate by facility staff and a licensed contractor.
• Inspect all doors, locks, and gates throughout the facility to ensure proper functioning.
• Add additional interventions to the resident’s care plan: increased supervision, q15-minute checks for 72 hours, and review of medications and labs.
• Adjust the exit door on the Memory Care Unit to prevent delayed egress.
• Review the Elopement Policy by the IDT to include individualized interventions for residents at risk for elopement.
• Audit new admissions weekly for 3 months to ensure elopement risk and interventions are in place.
• Complete elopement risk assessments on all residents.
• Educate MDS/Social Services on completing elopement evaluations, implementing interventions based on findings (including supervision/observation), and the necessity of staff availability and timely alarm response.
• Hold an Ad-Hoc QAPI meeting with leadership/IDT members to review the plan and findings.
• Forward elopement assessment audits to the Executive Director for QAPI Committee review monthly for at least 3 months to ensure ongoing compliance.
• Hold QAPI meetings monthly.
• Correct any deficient practices identified through monitoring immediately and report/review them through the QAPI Committee until ongoing compliance is achieved.
• Complete elopement drills each shift for 1 day and monthly ongoing.