Elopement of Cognitively Impaired Resident Due to Inadequate Supervision at Secured Exit
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement for one resident with severely impaired cognition. A registered nurse reported that on 2/7/26 at approximately 10:38 a.m., she was informed that a male resident was outside the facility without supervision and was subsequently found in a parking lot across the street. The RN stated the resident was alert but had impaired cognition, did not have an order to leave the facility, and was not safe to be outside without supervision. Review of the resident’s quarterly MDS dated 1/16/26 showed a BIMS score of 0, indicating severe cognitive impairment. A CNA reported that at approximately 10:30 a.m. on the same day, he opened the secured front entrance door to allow visitors to exit and did not recognize that the cognitively impaired resident was standing among the visitors. The CNA stated the resident exited the facility without supervision when the door was opened. The facility’s 5-Day Follow-Up Report documented that the resident exited through the front entrance after a newly hired CNA opened the secured door for visitors and did not recognize the resident as a non-visitor. Review of facility policies titled “Elopements and Wandering Residents” and “Accidents and Supervision” indicated that elopement is defined as leaving the premises or a safe area without authorization and/or necessary supervision, and that the facility will provide adequate supervision to prevent accidents.
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