F0689

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Elopement After Unsupervised Off‑Site Medical Appointment for Cognitively Impaired Resident

Garland, Texas Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and appropriate placement for a cognitively impaired resident with significant psychiatric and medical conditions, resulting in an elopement from a medical appointment. The resident was a 57‑year‑old female with schizoaffective disorder, bipolar disorder, major depressive disorder, mild intellectual disability, type 2 diabetes mellitus, and chronic venous ulcers. Her admission MDS showed a BIMS score of 7, indicating severe cognitive impairment, and her care plan identified adjustment issues, schizoaffective disorder, diabetes, and a chronic venous stasis ulcer, with a need for supervision and assistance for ADLs such as toileting, bathing, eating, and hygiene. She resided on the memory care unit prior to the incident and had been assessed as minimal risk for elopement on admission and again on an elopement assessment dated shortly after the incident.

On the day of the incident, the resident was transported alone by a facility-arranged driver to an off‑site vascular appointment. The driver dropped her at the door of the medical office and left; no staff accompanied her despite her psychiatric diagnoses, mild intellectual disability, diabetes, and prior residence on a secured memory care unit. At the physician’s office, she completed an ultrasound and was placed in a waiting room to await results. Office staff reported that around late morning she stated she did not want to wait, asked for a soda, and then walked out of the office against medical advice. Clinic staff searched the area and contacted campus security and later law enforcement, and the transport driver notified the facility that he could not locate her. The facility’s own investigation documented that she left the appointment AMA and could not be located, and that she was considered missing from that point.

The resident remained missing in the community for an extended period until she was located by public transportation police on a train in the early morning hours two days later. When interviewed after her return, she reported that she had taken public transportation downtown, purchased food and a drink, and attempted unsuccessfully to contact a previous SNF, stating she did not have contact information for her responsible party or the current facility. She was described as somewhat confused, with loss for words and inability to recall or respond to questions or details of events while she was gone, and she did not know her locations or contact information. Despite her complex psychiatric history, severe cognitive impairment documented on prior MDS, and diabetes requiring regular monitoring and insulin per sliding scale, the facility had assessed her as minimal elopement risk and did not provide increased supervision or ensure that staff accompanied her to the appointment. Additionally, after the elopement incident, she was not returned to the memory care unit but was instead placed on the main hall, despite her prior placement on the memory care unit before the event.