F0689

D

Failure to Maintain Exit Door Alarm Resulting in Elopement of High-Risk Resident

Highmore, South Dakota Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a resident identified as at risk for elopement, resulting in the resident leaving the building through an east exit door that was not alarmed or monitored. On the evening in question, an RN was unable to locate the resident at approximately 9:00 p.m. and initiated a search of the building, including rooms, closets, bathrooms, beds, and ancillary rooms. During this process, staff noted that the east door alarm was turned off, even though the resident’s care plan and the facility’s elopement policy required exit door alarms to remain on at all times for residents at risk of elopement.

The resident involved had a primary diagnosis of unspecified dementia with behavioral disturbances and a severely impaired cognition score on the Brief Interview for Mental Status. He had been assessed multiple times as having a potential risk for elopement, with elopement risk scores documented on admission and quarterly, and his care plan included interventions such as keeping all doors alarmed to alert staff and redirecting him if he was observed heading toward an exit. Despite these identified risks and care plan interventions, an LPN reported that she had turned off the east door alarm earlier that evening to allow another resident and family to enter without triggering the alarm and then forgot to turn it back on. Staff later confirmed that the door alarm did not sound when the resident exited the building.

After the resident was discovered missing, staff and visitors searched the facility and surrounding area. A citizen and his dog ultimately found the resident sitting on the ground in a neighbor’s yard across the street and alerted the search party. Weather data from a nearby personal weather station showed that at the approximate time of the elopement, the outdoor temperature was 7°F with wind speeds of 7 mph, resulting in a wind chill of approximately -5°F. When the resident was brought back inside, he was described as very cold to the touch, with an initial temperature of 96.4°F, and was noted to be combative and resistive to care, grabbing at staff and attempting to hit others, which staff reported was not his normal behavior. Subsequent observations and skin assessments showed no signs of frostbite, and his behavior documentation indicated that his behaviors returned to baseline after the incident.