F0689

J

Elopement of Severely Cognitively Impaired Resident Through Alarmed Stairwell Exit

Union City, New Jersey Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision for a severely cognitively impaired resident who was at high risk for elopement and exhibited exit‑seeking behaviors. The resident had a Brief Interview of Mental Status (BIMS) score of 2, indicating severe cognitive impairment, poor judgment, poor safety awareness, and an inability to recognize environmental hazards. The resident’s care plan identified a potential for wandering related to behavior and history of wandering, a risk for elopement due to exit‑seeking behavior with an intervention for a wander guard on the left ankle, and special needs for a protective head helmet due to a cranioplasty wound following a traumatic subdural hematoma and craniotomy. The resident was able to ambulate independently and had been admitted after a significant fall that resulted in brain surgery.

On the day of the incident, the resident was last seen by an RN at approximately 3:15 PM seated in a wheelchair in the back of the nurse’s station on the 6th floor. Around 3:25 PM, an LPN beginning the 3–11 shift observed the resident no longer in the wheelchair but slowly ambulating in the hallway toward the high side of the unit near the alarmed exit door and then sitting on a couch along that hallway. After reviewing the 24‑hour report, at about 3:35 PM the LPN went to look for the resident and found that the resident was no longer on the couch. The LPN began a room‑to‑room search of the 6th floor and informed the DON that the resident could not be found. A CNA arriving for the 3–11 shift at about 3:30 PM also reported looking for the resident and not seeing them.

During this same time frame, the social worker, whose office is across from the alarmed exit door on the 6th floor, returned to the floor and heard a door alarm sounding from the high side exit door. The social worker deactivated the alarm, looked down the stairwell, but only went down two to three flights and did not see anyone, then returned to the floor to inform nursing staff. The social worker and the LPN subsequently went down the stairwell to the bottom and noted that the exit door on the ground floor, which leads directly to a local street, was partially open; they checked outside and did not see any facility residents. The facility’s internal investigation and the resident’s later reenactment indicated it was probable that the resident had opened the 6th floor alarmed exit door, descended ten flights of stairs, and exited through the side egress door to the street. The resident was reported missing to police at approximately 4:17 PM and was later found by local police in a neighboring town and transported to a hospital emergency department for evaluation and overnight stay. The facility’s failure to ensure adequate supervision and to prevent this resident’s access to and use of the alarmed stairwell exit resulted in an elopement that constituted an immediate jeopardy situation beginning at the time the resident was last seen near the exit door.

Removal Plan

• Initiated an immediate room-to-room and in-house thorough search and initiated a foot and car search near the building perimeter
• Paged Code Gray to the entire building to alert all staff
• Informed local police about the missing person and provided the resident’s profile and description
• Notified the resident’s family and physician
• Alerted hospitals of the missing person
• Brought the resident to the emergency department for evaluation and the resident stayed overnight
• Completed a full head count of all residents in the building and confirmed all residents were accounted for
• Reassessed all residents at risk of elopement and re-evaluated care plans; determined interventions were appropriate and in place
• Upon the resident’s return, placed the resident on 1:1 supervision
• Upon the resident’s return, reassessed elopement risk and re-evaluated the resident’s care plan; deemed appropriate and in place
• Re-educated all staff on the facility’s Elopement and Wandering policy and continued ongoing re-education
• Implemented monitoring of the 6th floor East and [NAME] stairwell doors to ensure residents at risk have necessary supervision to prevent unsafe access to stairwell doors
• Placed a STOP sign barrier on both the East and [NAME] doors as an additional deterrent
• Requested a work order from the door security vendor for installation of an additional magnetic lock