F0689

J

Elopement of Cognitively Impaired Resident Through Malfunctioning Exit Door

Amarillo, Texas Survey Completed on 01-08-2026

Penalty

Fine: $12,740

Summary

The deficiency involves the facility’s failure to keep a resident’s environment as free from accident hazards as possible and to provide adequate supervision and assistance to prevent an elopement. The resident was an older adult male admitted with multiple serious diagnoses, including metabolic encephalopathy, protein-calorie malnutrition, hypertension, acute pulmonary edema, acute kidney failure, intestinal obstruction, enterocolitis due to C. difficile, and a cognitive communication deficit. His initial care plan identified altered neurological status, impaired cognitive function/dementia or impaired thought processes, and risk for falls, with interventions such as cueing, reorientation, monitoring for cognitive changes, and ensuring safe ambulation. At the time of the incident, the resident was on contact isolation for C. difficile and was independently ambulatory, and a Medicare 5‑day MDS documented that he scored 5/15 on a mini‑mental exam and was not capable of making informed decisions.

On the night of the elopement, the resident was last seen by staff during rounds at approximately 12:20 a.m. and was later found by local police at a nearby hotel about 0.4 miles from the facility, after he had left the building without staff knowledge. It was documented that the resident had walked to the hotel, where he attempted to obtain a room because he felt he was being held “hostage” due to being kept in isolation. Nursing documentation and an elopement evaluation sheet recorded that the resident exhibited cognitive impairment, pacing, exit‑seeking, and restlessness at the time of the event. The nurse’s notes also recorded the resident’s statement that he did not want to be in the facility and believed he was being held hostage, and that he was returned to his room by police, where a skin assessment showed no new injuries.

Prior to the elopement, there were indications of exit‑seeking behavior that were not acted upon in accordance with the facility’s elopement prevention expectations. An LVN reported that on the night before the elopement, the resident had tried to elope but was stopped at the door at the end of the hallway; the LVN described the resident as confused, repeatedly stating he did not want to be in the nursing home and trying to get out. The LVN later stated he did not inform anyone of this attempted elopement because the resident had not actually left the facility and he believed reporting was unnecessary. Speech therapy staff also reported that the resident was anxious, non‑compliant with the BIMS assessment, repeatedly stated he did not want to be there, and on a subsequent day was fully dressed with boots on and stated he was going home. A family member reported that the resident’s dementia was worsening, that he had recently lost his wallet and could not use his phone, and that he was very upset about being in isolation and not allowed to leave his room, all of which were consistent with the exit‑seeking and elopement behavior that ultimately occurred.

The facility’s own documentation acknowledged that staff reported the 400‑hallway exit door alarm and lock did not function properly at the time of the elopement, and that the door remained unlocked despite several attempts by nurses to reset the lock. The administrator stated that three nurses could not get the 400‑hallway door to lock. Although maintenance logs showed that door locks and alarms were checked on weekdays and the maintenance supervisor stated the 400‑hallway lock had been working the day before, on the night of the incident the malfunctioning door allowed the resident to exit the building unsupervised. The combination of the resident’s known cognitive impairment and exit‑seeking behavior, the lack of reporting and escalation of a prior attempted elopement, and the failure of the 400‑hallway door locking/alarm system resulted in the resident leaving the facility unnoticed and traveling to a nearby hotel, constituting the identified accident‑prevention deficiency.

Removal Plan

• Administrator assessed all exit doors for proper function.
• Staff were posted at all exit doors until the locking/alarm system was repaired by the vendor.
• Maintenance checked all doors for proper function.
• Facility door security vendor assessed and repaired malfunctioning doors/locks (including reworking mag lock wires, reinstalling strike plate, replacing timers and a keypad, and reworking timers).
• The delayed egress/locking mechanism activation time was reduced so the locking mechanism would activate sooner.
• Signs were posted on all exit doors with instructions on how to reset the alarm once the door was open.
• Large red 'Emergency Exit Only' signs were placed on all exit doors.
• Elopement in-service training was initiated/completed for staff (Elopement Response and Prevention – Code Orange).
• Elopement drills were conducted per protocol across shifts.
• Elopement risk assessments were completed on all residents.
• Daily monitoring/rounds were implemented to check for visitors or staff allowing residents to exit unsupervised (Missing Resident/Elopement Monitoring documentation completed daily).