F0689

J

Failure to Identify and Manage Elopement Risk for Cognitively Impaired Resident

Hagerstown, Maryland Survey Completed on 01-29-2026

Penalty

Fine: $21,665

Summary

The deficiency involves the facility’s failure to identify a cognitively impaired resident as an elopement risk and to implement interventions to prevent elopement, resulting in the resident leaving the building unsupervised. The facility had an elopement and wandering policy requiring residents to be assessed for elopement risk on admission and throughout their stay, with high‑risk residents to receive an alarm bracelet and an individualized care plan. On admission, the nursing elopement assessment for this resident was completed by an LPN, who marked the resident as unable to ambulate; this locked the remainder of the elopement assessment and resulted in the resident being deemed not at risk for elopement. This determination was made despite hospital records showing that prior to admission the resident had been living at home, driving, and working, and that during the hospital stay the resident could ambulate with a rolling walker and assistance.

Following admission, multiple clinical findings and events indicated that the resident’s condition and behavior had changed in ways relevant to elopement risk, but the facility did not reassess the resident for elopement until after the elopement occurred. Progress notes documented that the resident fell twice in the early morning of one day when attempting to get out of bed and walk, with staff noting the resident was unsteady. A care plan was initiated for noncompliance with using a walker. A Brief Interview for Mental Status determined the resident had severe cognitive impairment, and both the attending physician and a nurse practitioner documented that the resident was incapable of comprehending information and making decisions due to a hemorrhagic stroke. Therapy notes showed that the resident’s mobility improved, including ambulating 70 feet with a rolling walker and minimal assistance, which constituted a change in condition. Staff interviews later revealed that the resident frequently talked about going home, became more worked up when family prepared to leave, walked unassisted despite being unsteady, wandered without clear purpose, and had poor safety awareness.

On the day of the elopement, the resident was observed by the receptionist walking down the hallway carrying a wash basin with items and a shoebox, then exiting through the front door; the receptionist was unsure if the individual was a resident and did not intervene before the resident left the building. The resident’s assigned LPN and GNA reported they were passing dinner trays and checking blood sugars and did not see the resident leave the unit. A visitor arriving for a Thanksgiving event later found the resident lying on the ground in the visitor parking lot in dark, cold weather, still carrying the basin and shoebox. Another LPN leaving the facility also saw the resident on the ground behind a parked car and initially did not recognize the person as a resident until noticing an adult brief. When interviewed, the resident stated they had gone outside to go home. The facility’s own investigation concluded that the resident left the facility, was outside for several minutes, and was found lying in the parking lot, and that staff had not previously identified or care planned the resident as an elopement risk despite documented behaviors and functional abilities that met the facility’s own criteria for elopement risk.

The facility’s investigation file also showed that, prior to the incident, staff education on the elopement policy and elopement assessments had been started but not completed for all staff. Interviews with the interim DON and other staff confirmed that elopement assessments were expected on admission, quarterly, and with changes in condition or behavior, and that the resident’s behaviors—such as repeatedly talking about going home, packing belongings, and exit‑seeking—should have triggered reassessment. The NHA acknowledged that the resident was not being monitored as an elopement risk because the admission assessment had categorized the resident as not at risk, even though the NHA identified behaviors like wanting to go home and packing belongings as high‑risk indicators. These combined assessment failures, lack of reassessment after clear changes in condition and behavior, and lack of effective supervision and response to observed exit‑seeking behavior led to the resident’s elopement and subsequent fall in the parking lot, where the resident sustained an abrasion to the right side of the face and scrapes on both hands.

Removal Plan

• Resident #6 no longer resides in the facility.
• Complete updated elopement evaluations for all current residents to determine if any residents are at risk for elopement.
• Complete updated elopement evaluations by the Unit Managers and DON.
• Recheck alarm bracelets for proper placement and function for all residents determined to be at risk for elopement.
• Place any resident identified at increased risk for elopement on appropriate elopement precautions and update the care plan.
• Educate all facility licensed staff on the elopement policy and procedure, including the elopement risk evaluation process, to ensure elopement risk is reassessed.
• Educate all licensed nurses.
• Educate any licensed staff member unable to attend scheduled education upon arrival to the facility, and ensure education is provided prior to beginning their shift.
• Continue to educate all non-clinical staff on elopement policy and procedures, including identifying elopement risk signs and symptoms and reporting to appropriate clinical staff.
• Educate any facility staff member unable to attend scheduled education upon arrival at the facility, and ensure education is provided prior to beginning their shift.
• Validate education by administering quizzes randomly with 10% of staff weekly.
• Conduct audits monthly.
• Report findings at the monthly QAPI meeting to monitor progress towards improvement and recommendations.