F0689

D

Failure to Supervise Cognitively Impaired Resident Who Left Facility Unnoticed

Cedar Park, Texas Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure the resident environment remained as free of accident hazards as possible and to provide adequate supervision to prevent accidents, resulting in a cognitively impaired resident leaving the building without staff knowledge. The resident was an older male with vascular dementia of unspecified severity, generalized anxiety, and hypertension. His most recent quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and documented that he required supervision or touch assistance for ambulation distances of 10 and 150 feet, although he did not use assistive devices and was independently ambulatory. Despite this documented need for supervision with mobility and his cognitive impairment, the resident was able to exit the facility alone.

On the date of the incident, facility incident and accident records documented an elopement for this resident. Interviews and record review showed that the resident left the facility without alerting staff or signing out, walked down the road toward a nearby hospital where his wife was hospitalized, and then stopped at a bank when he became tired. From there, he called a family member, who in turn contacted the facility and learned that staff were unaware the resident had left. The family member reported concern that, although the resident was independent, he was under the facility’s supervision and should not have been able to leave without their knowledge. Staff interviews confirmed that the resident was not in his room at mealtime, which was not initially unusual because he often went for coffee, and that staff only became aware he had left when notified that he was being brought back.

Multiple staff, including the DON, NP, SW, CNA, and ADM, acknowledged that the resident had not previously exhibited exit-seeking behavior and was considered independent, alert, oriented, and with safety awareness. However, they also confirmed that he knew the exit code and could leave the building, and that the facility did not recognize his departure at the time it occurred. The ADM and DON stated they did not consider this a true elopement because the resident had intent, a plan, and safety awareness, and because he was allowed to walk outside unsupervised. At the same time, the facility had an existing expectation, communicated via an email from the senior vice president of clinical operations, that all residents leaving the building must be documented on a sign-out and sign-back-in log, with staff responsible for ensuring completion of the log before a resident goes out the door. The resident did not sign out, staff did not ensure the log was completed, and the facility did not know he was out of the building until contacted by the family member, demonstrating a failure to provide adequate supervision and to follow its own sign-out expectations to prevent accidents.

The email from senior leadership emphasized that the purpose of the sign-out log was to ensure the facility knew when residents were leaving, who they were leaving with, and to address safety concerns, including that not every resident should leave unaccompanied if there were questions about their safety. It also referenced the need to know which residents were in or out of the building during weather events, underscoring the safety rationale for tracking resident whereabouts. The blank sign-out form required the date, time leaving, resident name and signature, the printed name of the person leaving with the resident, staff initials, and the date and time of return with staff initials. In this incident, none of these procedures were followed for the resident who left alone, and staff interviews confirmed that all residents were under the care of the facility and should be supervised with staff aware of their location. The combination of the resident’s moderate cognitive impairment, documented need for supervision with ambulation, and the facility’s failure to monitor his whereabouts or enforce the sign-out process led directly to the deficiency.

Overall, the deficiency centers on the facility’s inaction in monitoring and supervising a resident with cognitive impairment and anxiety who was able to exit the building without staff knowledge, contrary to the facility’s own sign-out expectations. The resident’s departure was only discovered when a family member, contacted by the resident from a bank, notified the facility. Staff and leadership interviews confirmed that the resident was allowed to walk outside and knew the exit code, that there was no formal written policy beyond the email directive, and that the event was not reported as an elopement by the facility despite being documented as such in the incident log. These facts demonstrate that the facility did not ensure the environment was as free of accident hazards as possible and did not provide adequate supervision and assistance devices to prevent accidents for this resident.