F0689

J

Failure to Supervise High-Risk Wanderer on Secured Unit Resulting in Elopement

Beaumont, Texas Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a resident on a secured unit who was known to be at high risk for wandering and exit seeking. The resident was an adult male with early onset Alzheimer’s disease, dementia, bipolar disorder, anxiety, depression, alcohol abuse, and impaired cognitive function. His admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, with daily inattention and wandering. He was independent with mobility and ADLs such as walking and eating, and care plans identified him as at risk for wandering and elopement, requiring a secure unit and close supervision, including regular compliance rounds and assessment and reporting of potential elopement.

In the weeks leading up to the incident, multiple progress notes documented daily wandering, confusion, disorientation, restlessness, agitation, and repeated redirection needs. Staff reported that the resident frequently looked for his keys, wallet, and car, talked about leaving and going home, and wandered into other residents’ rooms, including a female resident’s room, prompting safety concerns from her family. Nursing and CNA staff stated that he had a history of elopement prior to admission, was placed on the secure unit for that reason, and required frequent monitoring and redirection due to exit seeking and wandering behaviors. Staff also reported that he did not have a consistent sleep pattern and some nights would be up pacing and wandering.

On the night of the elopement, the resident was last observed by evening staff around the late evening, when he was redirected to his room. The oncoming LVN and CNA for the night shift reported that when they began their shift and made initial rounds, they only “peeked” into his room and saw what appeared to be him lying in bed, and the CNA later left the secure unit to assist another CNA and then went to a break room to enter tasks. The resident had placed a sign on his door stating he did not want anyone entering his room, and staff did not enter the room to verify his presence. The facility remained unaware that he was missing until a family member and local police called around midnight to report that he was in police custody and being sent to a local ER. When staff then attempted to enter his room, they found the door barricaded with furniture, the TV face down on the floor, and the window broken, and the resident was gone. A police report and ER records showed that he had broken out through the first-floor secure unit window, used a bench in the courtyard to scale the fence, and was later encountered by police at nearby locations, including a fast-food restaurant where he was attempting to get into cars and was held at gunpoint by a bystander, before being transported to an ER. The facility’s lack of awareness of his absence for approximately 1.5 hours and failure to adequately supervise and monitor him on the secure unit led to the identified deficiency and Immediate Jeopardy.

Staff interviews after the incident consistently described the resident as someone who would attempt to elope if not under 1:1 supervision, with ongoing behaviors of wandering, pacing, exit seeking, and discussing ways to escape. Nurses and CNAs stated that he required close and frequent monitoring due to his cognitive impairment and behavioral history. Despite this known risk profile and care plan directives for close supervision and regular rounds, the resident was able to barricade his door, remove window trim and locks, break the window, access the courtyard, and climb the fence without detection, and the facility did not identify his absence until notified by external parties. This sequence of events, combined with the documented knowledge of his elopement risk and behaviors, formed the basis of the surveyors’ finding that the facility failed to ensure adequate supervision and prevent accidents for this resident.

Removal Plan

• Resident #1 was placed on 1:1 monitoring until transferred to behavioral hospital.
• All residents received an elopement risk assessment completed by DON, ADON, and designee; no additional findings were identified.
• All secure unit residents were assessed and monitored after the incident by LVNs, DON, ADON, and designee; no additional findings were identified.
• Door code was changed.
• Damaged furniture was replaced.
• Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on: Abuse and Neglect; Resident Rights; Elopement Prevention; Elopement Response.
• Medical Director was notified of the Immediate Jeopardy by the DON.
• An ADHOC QAPI meeting was conducted by the interdisciplinary team, including the Medical Director.
• Elopement drills were conducted on all shifts by Administrator/Designee.
• In-services were initiated for all direct care staff by the DON, ADON, and/or Regional Compliance Nurse (in person and/or via phone); staff not present were not permitted to work their assignment until in-serviced; new hires will be in-serviced during orientation; agency staff will be in-serviced prior to working their floor assignment.