F0689

J

Elopement of Cognitively Impaired Resident Due to Inadequate Supervision at Secured Exit

Tylertown, Mississippi Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one resident who was newly admitted with dementia, delusional disorder, hallucinations, and a documented history of wandering. The resident’s admission MDS showed a BIMS score of 3, indicating severe cognitive impairment, and identified a history of wandering, while functional assessment documented that the resident could ambulate independently for 150 feet. The admission history and physical from the community setting described dementia with agitation and psychosis, aggressive behaviors and irritability related to attempts to cross the street, and agitation when unable to perform desired activities such as going across the road. The physician had previously discussed safety issues with the family and recommended additional door locks at home to prevent wandering and leaving the house. Upon admission, the facility had a physician order to monitor wandering and elopement for 14 days and an active order to monitor behavior each shift for anxiety, restlessness, and pacing.

On the morning following admission, the resident was observed by an LPN at approximately 10:35–10:40 a.m. sitting on the side of the bed and had been seen walking in the hallway and to the nurse’s station earlier in the day. Around 11:30–11:40 a.m., when staff were preparing lunch, a CNA was unable to locate the resident in the room, dining room, or therapy area and notified nursing staff that the resident might be missing. A brief search inside the facility was conducted before the DON was notified and a missing resident code was called overhead. Staff then initiated a broader search of the building and surrounding outside areas after learning the identity of the missing resident.

The Administrator later reviewed security camera footage and determined that a dietary aide had assisted the resident with the front entrance door. The dietary aide reported that she had seen the resident at the front door, did not know who he was, and entered the numeric code into the keypad to disengage the lock, allowing the resident to exit the building unaccompanied and unsupervised. The facility’s elopement and wandering policy stated that residents at risk for elopement were to receive adequate supervision, that interventions were to be added to the care plan and communicated to staff, and that door locks/alarms and a systematic approach to monitoring and managing residents at risk were to be used. At the time of the incident, the facility relied on staff-held numeric codes for exit doors and did not have a two-part safe wandering system with resident-worn monitors and corresponding door monitors. The resident was ultimately located by the maintenance technician approximately 0.5 miles from the facility, sitting on the steps of a local business, and was returned to the facility.

Interviews with staff confirmed the sequence of events and the lack of recognition of the resident’s identity and risk status at the exit door. The Administrator confirmed that the dietary aide had not checked with nursing staff before entering the door code and allowing the resident to leave. The maintenance technician stated that, regardless of the route taken, the resident would have had to cross two of the busiest streets in town to reach the location where he was found. At the time he was located, the resident’s clothing and shoes were clean and dry, and staff assessments upon return noted no injuries or pain. The facility’s failure to ensure that a resident with known severe cognitive impairment and a history of wandering was adequately supervised, and to prevent an untrained staff member from facilitating his exit through a secured door, resulted in the resident leaving the facility unnoticed and unsupervised.

Removal Plan

• Initiated Code [NAME] (missing resident) and began facility-wide search when Resident #1 could not be located.
• Notified the Administrator immediately via Code [NAME].
• Notified the physician.
• Notified the resident representative.
• Completed a head count to ensure all other residents were accounted for.
• Expanded the search throughout the facility.
• Expanded the search outside the facility and assigned maintenance staff to search by vehicle.
• Located Resident #1 off-site and returned the resident safely to the facility.
• Physician assessed and evaluated Resident #1 upon return; no injury noted.
• LPN performed a full body audit upon return; no injury noted.
• RN performed a pain assessment upon return; no pain verbalized.
• Placed Resident #1 on one-on-one (1:1) monitoring upon return.
• Reassessed Resident #1 for wander and elopement risk (moderate risk).
• Updated Resident #1 care plan to include one-on-one (1:1) monitoring.
• Verified all doors were functioning properly.
• Audited residents to identify risk for wandering and elopement and identified additional residents at risk who continued to be monitored.
• Reported the event to the Mississippi State Department of Health Hotline.
• Reported the event on the Attorney General Medicaid Fraud Site.
• Reviewed the Wander and Elopement Binder to ensure updated risk assessments and current photos for residents at risk.
• Updated colored signage instructing staff to check with nursing before allowing anyone out the door.
• Suspended the Dietary Aide pending investigation and terminated employment.
• Held an emergency QAPI meeting.
• Completed facility-wide education/in-services on the Elopement and Wandering Residents Policy, Code [NAME] Policy, identifying residents at risk for elopement, and resident identification protocols.
• Conducted elopement drills on each shift.
• Implemented ongoing monitoring of staff competency/knowledge regarding wandering risk and safety awareness using scheduled knowledge testing.
• Implemented monitoring of the Elopement Binder to ensure each at-risk resident has a current photograph and up-to-date risk assessment.
• Implemented monitoring of residents at risk for wandering/elopement to ensure alert band placement, with planned replacement by safe wandering system bracelet placement upon installation.