F0689

J

Failure to Prevent Elopement and Inadequate Supervision of High-Risk Residents

Brenham, Texas Survey Completed on 01-20-2026

Penalty

Fine: $25,500

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for residents at risk of elopement, resulting in one resident leaving the building unsupervised and another high-risk resident being left outside alone. One resident, a female with type II diabetes mellitus, congestive heart failure, hypertension, acute kidney failure, major depression, and schizoaffective disorder, bipolar type, had a BIMS score of 8 indicating moderate cognitive impairment. Her care plan was updated after the incident to identify her as an elopement risk/wanderer. On the day of the elopement, she was last seen by an LVN shortly after 6:00 a.m. when she refused Accu-Checks and again around 7:40 a.m. near the breakfast room. A CNA reported that she delivered the resident’s breakfast tray around 7:50 a.m. and found the resident missing when she returned around 8:40 a.m. to pick up the tray.

Video footage later showed this resident walking unattended in the front living room area at 8:15 a.m. and exiting the front door at 8:16 a.m. without staff supervision. The facility’s Administrator reported that the resident exited by using the door code and stated she had no prior knowledge that the resident knew the code, speculating that the resident must have obtained it from her boyfriend, another resident. The Administrator also stated that the master door code had not been changed since 2024 and that it had not been changed due to the perceived financial cost of updating all door codes. The facility’s elopement policy required prompt search and notification procedures once a resident was found missing, but the report documents that the resident was ultimately located offsite by a security guard at a local credit union approximately 0.5 miles away after crossing a busy frontage road, and was transported by EMS to a hospital ER, where she was found in an altered mental status.

A second resident, a male with hemiplegia and hemiparesis affecting the left dominant side, dysphagia, and contractures of the left shoulder and elbow, had a BIMS score of 11, also indicating moderate cognitive impairment. His care plan included a focus that he often went outside and sat at the front entrance without alerting staff of his whereabouts, and he was identified as an elopement risk/wanderer with impaired safety awareness. Interventions included monitoring his whereabouts each shift and ensuring a functioning Wander Guard device. Despite this, observation showed this high elopement-risk resident sitting outside on the patio alone and unsupervised. The Administrator acknowledged that this resident knew the door code prior to her employment, that his knowledge of the code overrode the Wander Guard system, and that most Wander Guard devices in the facility were visual only and did not alarm. The Administrator stated there was no policy addressing residents with high elopement risk having knowledge of the master door code. These actions and inactions related to door code management, Wander Guard use, and supervision of residents at risk for elopement led to the identified deficiency under F689 for accidents and supervision.

Removal Plan

• Complete elopement risk assessments for all residents to ensure ongoing evaluation and implementation of appropriate preventive interventions.
• Implement a universal reset of the master door code to reduce the risk of unauthorized exit and elopement due to Resident #1's demonstrated knowledge of the door access code.
• Complete a facility-wide in-service for the Administrator and Maintenance Director on door code security and the requirement to report any known or suspected door code breach to the Maintenance Director and/or Administrator, with signature acknowledgment.
• Implement a camera monitoring system at the nursing station to enhance supervision of residents and monitor exit activity.
• Restrict authorization to initiate and implement door code changes when codes are compromised or breached to only the Maintenance Director and Administrator.
• In-service the Director of Nursing on operation, monitoring expectations, and response procedures related to the camera monitoring system, with signature acknowledgment.
• In-service charge nurse staff and agency staff on operation, monitoring expectations, and response procedures related to the camera monitoring system prior to start of shift, with signature acknowledgment.
• Include education on camera monitoring and reporting procedures as a required component of new hire orientation and policy change.
• Include education on door code security and reporting procedures as a required component of new hire orientation.
• Contact the door system manufacturer or security system company to request and coordinate the change of all access and exit door codes.
• Maintain sole possession of the master door code and all instructions for code changes by the Maintenance Director and Administrator.