F0689

J

Failure to Supervise High-Risk Resident Resulting in Elopement

San Antonio, Texas Survey Completed on 01-16-2026

Penalty

Fine: $14,020

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a cognitively impaired resident who was known to be at risk for wandering and exit-seeking. The resident was an adult male with dementia, adjustment disorder, alcohol abuse, and psychosis, with a BIMS score of 06 indicating severely impaired cognition. Prior assessments identified him as an elopement risk, with multiple Elopement Risk Assessments scoring in the elopement risk range. His prior MDS indicated daily wandering behavior, and progress notes documented repeated expressions of wanting to leave the facility to visit a former resident friend, including a statement that he wanted to walk to another city to see this friend. Staff notes also described the resident pacing in front of the exit door, focusing on the door instructions, and stating he "just want[ed] out" to see his friend.

Despite these indicators, the resident’s care plan did not include comprehensive interventions addressing his ongoing elopement risk. The care plan documented that the resident wanted to go across the street to visit his friend and that he had previously left the facility without notifying staff to go to a corner store, but there was no detailed care planning related to continued elopement risk. Progress notes showed that the resident had been placed on 1:1 monitoring after a resident-to-resident altercation and was later placed on every 15-minute monitoring due to anxiety, agitation, and exit-seeking behaviors. However, during the period leading up to the elopement, staff documentation reflected that the resident continued to pace, use the elevator between floors, and focus on the exit door, indicating ongoing exit-seeking behavior.

On the day of the elopement, the resident was identified as high risk for elopement and was to be monitored every 15 minutes. RN B documented that the resident was in the hallway on the second floor prior to dinner and that the CNA invited him to join other residents in the dining room while the nurse was watching the dining room and feeding residents. During this time, the resident went downstairs unobserved and exited through the front door. Staff were not aware that he had left the facility because he did not sign himself out. The resident remained out of the facility for approximately 30 minutes and was later found at a nearby convenience store and returned by a former employee. The RCN reported that the elopement occurred after a staff member failed to ensure the front door was fully closed upon entering for a scheduled shift, and that the resident should have been visually checked every 15 minutes as ordered, but RN B failed to ensure those observations were conducted. These actions and inactions resulted in the resident eloping from the facility without staff knowledge or supervision.