F0610

D

Failure to Thoroughly Investigate Resident Elopement

Kettering, Ohio Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct a thorough investigation after a cognitively impaired resident, identified as being at risk for elopement and residing on a secured Memory Care Unit (MCU), left the facility grounds. The resident had multiple diagnoses including dementia, schizoaffective disorder, bipolar disorder, and anxiety, and had been assessed as at risk for elopement upon admission. The care plan documented impaired cognition, poor judgment, and elopement risk, with interventions such as monitoring cognitive changes, conducting elopement assessments, and providing redirection. On the day of the incident, behavior notes documented that the resident was setting off alarms and attempting to exit the MCU, with staff redirecting the resident and securing the unit doors. Later that afternoon, staff discovered the resident was not in the facility, initiated a missing resident code, and began a search.

Interviews revealed inconsistent accounts of how and by whom the resident was located and returned, including reports that the resident was found approximately 0.75 miles away on a public road and transported back by staff. The Administrator and nursing staff gave differing descriptions of the circumstances of the resident’s return. The DON confirmed there was no documented evidence of a thorough investigation into the elopement, including no documentation of when the resident was last seen, how the resident exited the secured unit, or what steps were taken to prevent recurrence. The DON also verified that the facility did not provide education to all staff members on elopement risks, despite a written wandering and elopement policy that required assessment of residents at risk and review of the situation by the DON, physician, resident, and representative after an elopement event.