F0689

D

Failure to Supervise Elopement-Risk Resident During Vendor Traffic

Saluda, North Carolina Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to effectively supervise a cognitively impaired resident who was assessed as being at risk for elopement and who exited the building unsupervised and without staff knowledge. The resident had diagnoses including dementia, bipolar disorder, panic disorder, and anxiety disorder, and an MDS documented severe cognitive impairment with a need for supervision for mobility and transfers. The resident’s care plan, initiated and updated prior to the incident, identified risk of elopement with behaviors such as standing by exit doors, verbalizing intent to walk out, and attempting to follow staff as they exited. Interventions on the care plan included 1:1 approach during elopement attempts, redirection from the front door area with offers of coffee, snacks, walks in the courtyard, or return to the room, and maintaining a calm environment.

An elopement assessment completed prior to the incident documented that the resident was independent with ambulation and exhibited exit-seeking behaviors, including verbalizing a desire to go home or go on a trip, and not accepting the current residence. Despite this, the immediate intervention listed was to continue the current plan of care. On the morning of the elopement, the DON and Administrator reported that the resident had shown increased exit-seeking behavior, including asking about leaving and standing near common area doors that were locked with a keypad. This escalation was discussed in the morning interdisciplinary team meeting, and staff were informed they needed to increase observation and redirection of the resident due to the heightened behaviors.

On the day of the incident, Nurse #1 reported that around 10:10 a.m. the resident was inquiring about leaving the facility; she told him he needed to talk to the physician and that it was almost time to go smoke. The resident then left the nurse’s station and went to his room, where he lay on his bed. NA #1 stated that at approximately 10:30 a.m. the resident was in his room sitting on his bed after she had redirected him with an offer of coffee when he asked how he could get home. NA #1 acknowledged she was aware of his exit-seeking behavior and the need to keep an eye on him but stated she had other residents to care for and could not continuously watch him. At 10:42 a.m., Nurse #1 saw the resident outside, midway down the facility driveway, approximately 150 feet from the building and about 50 feet from the road, and immediately brought him back inside. The facility’s investigation concluded that, on a day when multiple vendors and staff were entering and exiting through a side common area door, the resident was able to leave the building by following or being let out by a vendor or staff member through that door, resulting in an unsupervised exit despite his known elopement risk and recent increase in exit-seeking behavior.

Interviews with the NP indicated that during prior visits the resident had always been observed sitting on his bed and had not shown exit-seeking behavior to her. However, staff interviews and documentation on the Kardex and elopement assessment confirmed that exit-seeking behaviors were known and that the resident was identified as at risk for elopement. The side common area doors used by vendors were locked with a keypad, and only certain management staff had the code, but on the day of the incident vendors and staff were going in and out through those doors, and the resident was able to leave undetected. The combination of known elopement risk, documented increased exit-seeking behavior that morning, reliance on intermittent observation rather than continuous supervision, and active vendor traffic through a secured exit led to the resident’s unsupervised departure from the facility.