F0689

J

Failure to Supervise Exit-Seeking Resident Resulting in Unnoticed Elopement to Courtyard

Indianola, Mississippi Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a resident with known exit-seeking behaviors, resulting in the resident leaving the building and remaining outside unsupervised in cold weather. The resident had a diagnosis that included unspecified dementia and was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 3. Earlier assessments identified the resident as high risk for wandering on 6/24/25, low risk on 11/7/25, and again high risk on 12/31/25. A wander bracelet ordered in June 2025 for dementia and exit-seeking behaviors was discontinued on 10/28/25. On 12/8/25, a Social Services Progress Note documented that the resident was agitated, sitting in the lobby doorway, yelling that he wanted to go home, tapping on the door, and requiring redirection by nursing staff. The Social Worker later confirmed that these were exit-seeking behaviors and acknowledged that additional interventions such as increased monitoring and a wandering assessment should have been implemented but were not.

On 12/30/25, staff documented in the Plan of Care Response History at 11:18 AM that the resident exhibited behavioral symptoms of wandering, noted that these behaviors had occurred previously, and documented that the nurse was notified. Multiple staff interviews confirmed that the resident was known to be exit-seeking on a daily basis and required frequent redirection, yet several CNAs and an LPN assumed the resident already had a wander guard in place when he did not. That evening, the resident was last observed by his assigned CNA watching television in the lobby a little after 7:00 PM. At approximately 7:28 PM, the resident exited the facility through the smokers’ courtyard door. The door was later found by the Maintenance Director to have a malfunction in which sustained pressure on the handle allowed it to open without sounding an alarm. Staff near the courtyard, including a CNA who had been in the breakroom by the exit until about 8:30 PM, reported not hearing any alarm and did not observe anything unusual during that time.

The resident was eventually discovered outside when a CNA walking down the hall looked through the courtyard door and saw someone sitting on the patio. The CNA obtained another CNA, who identified the individual as the resident. The resident was brought back inside, and staff observed that he was shivering, rubbing his hands together, and that his hands appeared white or pale. The resident later stated he had gone outside at night because he wanted to meet his girlfriend, walked around the yard, and tried to come back in but found the door locked. He reported sitting outside for a long time before someone opened the door and stated he was shaking and very cold when he returned inside. Vital signs, including body temperature, were not obtained until the following morning at 10:50 AM. The incident occurred when outside temperatures were documented as ranging from 32 to 34 degrees Fahrenheit between 8:00 PM and 9:00 PM. The combination of the resident’s known exit-seeking behavior, lack of enhanced monitoring or wandering interventions after documented behaviors, discontinuation and absence of a wander bracelet, staff assumptions about his elopement protections, and a malfunctioning courtyard door that could be opened without an alarm led to the resident’s unsupervised exit and exposure to cold conditions.

The situation was determined by the State Agency to constitute Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) at 42 CFR §483.25(d)(1)(2), Free of Accident Hazards/Supervision/Devices (F689), with an IJ level of scope and severity J beginning on 12/8/25, when the resident began exhibiting exit-seeking behaviors. The IJ and SQC were formally communicated to the facility’s Administrator on 1/12/26 at 4:30 PM, and the IJ template was provided. The IJ level was later reduced from J to D after validation that corrective actions in the facility’s removal plan had been completed, while the facility continued to develop and implement a plan of correction and monitor systemic changes for sustained compliance.

Removal Plan

• CNA found Resident #1 unattended on the courtyard patio, brought him back to the facility, and another CNA took him to his room and alerted the charge nurse.
• RN notified the DON that Resident #1 had exited the building and was found in the courtyard.
• DON notified the Administrator; Administrator instructed 1:1 monitoring for the remainder of the night, instructed DON to call Maintenance to check the door, and instructed that a head count of all residents be done immediately.
• DON notified Maintenance to return to the facility and check the door.
• Resident #1 was assessed by nursing with no ill effects.
• DON instructed a CNA to stay with Resident #1 1:1 for the remainder of the night.
• Maintenance checked the door, found it would open if the handle was compressed longer than 10 seconds, adjusted the bolt to disable the feature so the door would not open, and checked all doors and windows.
• Maintenance notified the DON that the door was corrected, room checks had been done, and all residents were accounted for.
• Resident #1 was assessed as a wandering risk and a signaling device was placed on his wrist for monitoring.
• Social Services updated the Residents at Risk for Elopement in the Elopement Binder.
• Elopement drills were started.
• The Administrator reported the incident to the Mississippi State Department of Health and Licensure.
• The Mississippi Attorney General's Office was notified of the incident.
• An Ad-Hoc QAPI meeting was held to discuss the incident and findings from the State Surveyor.
• The DON conducted an audit of residents at risk for elopement to review wander risk care plans for those residents identified as at risk for wandering.
• In-services began for all staff on elopement, resident rights, proper door functioning, abuse/neglect/reporting, and notifying staff of observed behaviors; staff were not allowed to work until the in-service was completed.
• A revised Ad-Hoc QAPI meeting was held to discuss the incident and findings from the State Surveyor.
• Audit findings for residents at risk for elopement were reviewed with the Administrator, DON, and ADON.
• The Ombudsman was notified.