F0689

J

Elopement of Exit-Seeking Resident from Unsecured Courtyard Gate

Wells, Texas Survey Completed on 01-07-2026

Penalty

Fine: $19,120

Summary

The deficiency involves the facility’s failure to keep the resident environment as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents for a resident with known exit-seeking behaviors. The resident was an adult male with dementia, impaired memory, impaired decision-making, and a documented history of elopement risk and wandering. He had been assessed as an elopement risk, was disoriented to place, had a history of attempts to leave the facility unattended, and was admitted to and residing on a secured male unit specifically due to active exit-seeking behaviors and elopement attempts.

On the day of the incident, staff reported that residents from the secured male unit, including this resident, attended a Christmas party in the main dining room. CNAs working the unit stated that all or most residents were taken to the party, with one CNA remaining on the unit because one resident did not attend. After the party, residents were assisted back to the secured unit. At some point after the return from the party, the resident was allowed into the secured unit’s courtyard without staff supervision. Staff interviews indicated that an aide had let the resident out into the courtyard unsupervised, despite his known elopement risk and the facility’s practice that residents in the courtyard must be supervised.

The courtyard was enclosed by a wooden fence with a gate equipped with a magnetic lock and keypad. On the day of the incident, the gate’s magnetic lock was not functioning properly, and the gate was unlocked, allowing the resident to exit the courtyard and leave the facility grounds. The maintenance supervisor reported that he had conducted a generator test earlier that day and had reactivated the magnetic locks on the doors and courtyard gate, and that they were working at that time. However, after this check, the gate lock failed and the resident was able to walk out through the open gate. The facility was unaware that the resident was missing until a speech-language pathologist, who had left for the day, saw him walking in a nearby library parking lot near a main highway, picked him up, and returned him to the facility. At the time he was found, the resident stated he was looking for his car. The facility’s failure to ensure the courtyard gate remained secured and to provide continuous supervision for a known elopement-risk resident in the courtyard led to the elopement event.

Removal Plan

• Update Resident #1's comprehensive care plan to add interventions after the elopement (monitor for emotional distress for 72 hours, complete head-to-toe assessment for injuries/abnormalities, notify physician and family, provide additional staff training on elopement and review policy/procedure, ensure resident is supervised while in the courtyard and not left unattended, and update the elopement risk assessment).
• Complete an incident report for the elopement and notify the physician and family.
• Complete a comprehensive assessment.
• Complete emotional distress assessments.
• Complete a new elopement risk assessment.
• Provide staff in-service training titled 'Secured unit outside supervision'.
• Provide staff in-service training titled 'Elopement and Wandering Residents'.
• Initiate every-15-minute head counts on the male secured unit.
• Install a camera at the courtyard gate and monitor it with a log until the gate is repaired.
• Conduct elopement drills for day and night shifts.
• Repair the exterior gate by replacing the magnetic lock and z-bracket to restore proper function.
• Ensure residents on the male secured unit are supervised when outside in the courtyard.