F0656

J

Failure to Update Care Plan for New Exit-Seeking Behaviors Leading to Elopement

Brinkley, Arkansas Survey Completed on 02-23-2026

Penalty

Fine: $14,020

Summary

The deficiency involves the facility’s failure to develop and implement an effective, updated comprehensive care plan with individualized interventions in response to new onset wandering, exit‑seeking, and elopement‑related behaviors for a resident on a secured unit. The resident had a history of traumatic brain injury, cerebral infarction (stroke), altered mental status, and was admitted to the secured unit due to traumatic brain injury and elopement risk. A quarterly MDS showed the resident was cognitively intact with a BIMS score of 12 and independent with ambulation, but a later BIMS showed a score of 2, indicating moderately impaired cognition. Despite these changes and the resident’s known elopement risk, the care plan initiated months earlier contained only general interventions such as therapeutic activities and medication monitoring, and no additional or revised interventions were added after 08/25/2025 to address later‑emerging behaviors or elopement attempts.

On 01/13/2026, multiple progress notes documented significant behavioral changes and explicit exit‑seeking behavior. Early that morning, staff recorded that the resident was up all night walking the halls, refusing to go to bed, entering other residents’ rooms, and voicing that they did not live in the facility. The resident stated an intent to get out of the window. Later that day, another note documented that the resident had been seeking elopement since returning from a home visit, admitted a desire to leave, had been looking for ways to get out, and followed staff out locked doors, showing force when staff tried to return the resident to the unit. A further note that evening described the resident talking loudly, being aggressive toward staff, and again stating a desire to get out of the facility. Although an elopement assessment was completed at that time, there were no new care plan interventions put in place to guide staff in preventing exit‑seeking or managing the aggressive behaviors.

In the weeks that followed, staff interviews and documentation showed that the resident continued to exhibit wandering and exit‑seeking behaviors without corresponding care plan revisions. Staff reported that after a family home visit, the resident began trying to leave the unit, walked door to door asking how to get out, watched staff to see if they were paying attention, and talked about leaving. On the night of the elopement, camera footage showed the resident repeatedly moving between the room, day room, and bathroom before entering the room and not re‑emerging. A CNA on duty stated that the resident had been going in and out of the room earlier in the shift, then went back to the room and was not checked on again; the CNA also reported dozing off during the shift and not hearing the window break. In the early morning hours, staff discovered the resident’s window busted and the resident missing, and a progress note documented that the resident had eloped by throwing an end table through the window. A police report and interviews confirmed that the resident was found off‑site after nearly being struck by a vehicle, having left the facility to find family. Throughout this period, the facility did not update the resident’s care plan with individualized, effective interventions to address the clearly documented new onset wandering, exit‑seeking, and elopement behaviors.

Removal Plan

• Revise Resident #1's care plan to include individualized elopement prevention interventions updated to include all interventions per the Plan of Removal.
• Complete new elopement risk assessments for residents residing on the secured unit.
• For any resident scoring moderate or high risk, review care plans to ensure individualized elopement interventions are present.
• Complete environment exit safety checks.
• Revise and update all secured unit residents' care plans based on the Plan of Removal.
• Provide in-service education to nursing and direct care staff on the elopement policy and missing resident procedures.
• Provide in-service education to nursing and direct care staff on the definition and examples of elopement and exit-seeking behaviors, early warning signs requiring interventions, and requirements to notify the nurse, administrator, or DON of new or increased behaviors.
• Provide in-service education to nurse management responsible for updating care plans on mandatory care plan revision following behavior changes with individualized interventions.
• Order shatter-resistant film for front-facing secured unit windows and install it.
• Implement monitoring for the DON or designee to review the 24-hour report to identify new or increasing exit-seeking behaviors.
• Implement monitoring for the DON or designee to complete audits to verify elopement risk assessments are completed, individualized interventions are present, and documentation reflects staff implementation, then transition to routine QAPI monitoring.