F0689

J

Failure to Supervise High-Risk Resident Resulting in Multiple Elopements

Lawton, Oklahoma Survey Completed on 01-22-2026

Penalty

Fine: $17,630

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident with severe cognitive impairment and a documented high risk for elopement. The resident had dementia, anxiety, a severely impaired BIMS score of 2, and was independently ambulatory, with assessments repeatedly identifying them as high risk for elopement. Despite this, the resident experienced multiple episodes of exit seeking and elopement over several months, beginning with an incident in which the resident walked out the front door with visitors and had to be redirected back inside by staff after other residents alerted them. Subsequent nursing notes documented wandering, exit-seeking behaviors, and attempts to follow others out of the building.

The facility’s documentation showed repeated incidents where the resident exited or attempted to exit the building by following visitors, delivery drivers, or other residents through the front door. On one occasion, the resident was observed outside walking toward a storage facility next door near a busy street and was described as agitated, difficult to redirect, and continuing to exit seek. Another incident documented the resident being found outside by the curb and returned to the facility by a staff member’s car after a visitor notified staff. In several of these events, staff were not initially aware the resident had left the building and only became aware after being notified by others or upon observing the resident outside.

Although the facility intermittently placed the resident on one-on-one supervision following some of these incidents, the one-on-one forms were not completed with time intervals to show that the supervision was actually provided, and this increased supervision was not incorporated into the resident’s care plan. The care plan, revised later, did include a focus related to elopement and listed interventions such as distraction with activities, observing for fatigue and weight loss, observing location in the community, and providing directional cues. However, it did not show that supervision interventions were updated or increased after the resident’s repeated exit-seeking behaviors and documented elopements. Staff interviews further revealed that direct care staff were not consistently aware of the resident’s elopement risk, relied on word of mouth or the care plan to identify such residents, and expressed uncertainty about what to do when a resident had multiple elopement attempts. The DON acknowledged that the resident had eloped to the parking lot near a very busy street and identified a system failure related to incomplete one-on-one documentation and the lack of care plan updates to ensure adequate supervision after multiple elopement-related events.

An Immediate Jeopardy situation was determined to exist due to this failure to ensure adequate supervision to prevent elopement for the resident. The survey findings noted that the facility’s own elopement and wandering policy required adequate supervision and care in accordance with a person-centered care plan for residents at risk of elopement. Despite multiple high-risk assessments and repeated incidents of exit seeking and elopement, the facility did not consistently implement, document, or care-plan increased supervision measures for the resident. Direct care staff reported gaps in communication and training regarding elopement risk and interventions, and the resident’s representative stated they were not informed when the resident was placed on one-on-one supervision and ultimately moved the resident to another facility with a memory care unit because the resident was not safe due to exit seeking attempts and elopements.

Removal Plan

• Elopement Risk Assessments were completed on all residents.
• Facility developed and implemented care plans to address elopements for all residents identified as at risk for elopement.
• An At-Risk Elopement Book with care plan was created and posted at the nurse's station, accessible only to staff, in accordance with HIPAA requirements.
• All nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee(s).
• Elopement and wandering residents' policy was reviewed.
• Facility implemented a monitoring sheet for residents at risk for elopement.
• An Elopement Response Drill schedule was implemented, with drills occurring on all shifts.
• The DON or designee will perform a daily audit of clinical data to ensure adequate supervision is in place for residents with active wandering and elopement risk.