F0689

J

Failure to Implement Resident-Centered Elopement Protections for High-Risk Resident

Fort Collins, Colorado Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a cognitively impaired resident at high risk for elopement. The resident had Lewy body dementia, parkinsonism, orthostatic hypotension, repeated falls, and severe cognitive impairment with a BIMS score of 4/15. He required supervision to substantial assistance for most ADLs and needed supervision to touching assistance to walk ten feet. Despite these needs, an initial elopement assessment after admission concluded he was not at risk for wandering, documenting no memory or decision-making impairments and no verbalization of wanting to leave, even though he was cognitively impaired and ambulatory.

Beginning in late September and throughout October and November, progress notes documented frequent wandering, pacing, agitation, paranoia, and exit-seeking behaviors. The resident was found wandering near an elevator, stated he was trying to find his way out, and had a fall associated with poor safety awareness and cognitive decline. He repeatedly required PRN lorazepam and later Seroquel for anxiety, agitation, pacing, packing and unpacking belongings, rummaging, hyper-fixation on leaving, and beliefs that he was in a hotel and needed to check out or that he needed to rescue his sister. Hospice and physician notes addressed medication management but did not address his wandering, packing, pacing, or elopement behaviors with nonpharmacologic interventions. Despite this pattern, the facility did not develop or implement a resident-centered elopement care plan that specified effective nonpharmacologic interventions or the level of supervision he consistently required.

On one occasion, the resident left the building and walked with his walker toward a nearby school, stopping in the middle of a street crosswalk and asking passersby to call the police before staff redirected him back inside. An elopement risk evaluation completed that day scored him as high risk, noting dementia, memory and decision-making impairments, verbalization of wanting to leave, wandering with and without his walker, ineffective verbal redirection, and inability to find his room without hands-on assistance. The IDT reviewed this elopement and attributed it to confusion and paranoia, adding 15-minute checks, but did not document the duration of these checks or add consistent, nonpharmacologic elopement interventions to the care plan. Later, the resident again left the facility at night without his walker and was found outside at a locked back door attempting to reenter; 15-minute checks and line-of-sight observation were used temporarily, but his 15-minute check sheet for part of that time was left blank. Progress and hospice notes continued to document wandering, restlessness, and exit-seeking, and a subsequent elopement risk evaluation showed an even higher risk score, yet the facility still did not initiate a resident-centered elopement care plan or clearly define required supervision. Staff interviews further revealed that the resident often sat in the front lobby near an unlocked front door that was infrequently monitored by staff, underscoring the lack of consistent supervision in an area of easy egress.

Removal Plan

• Place Resident #13 on one-to-one supervision indefinitely.
• Review and update Resident #13's care plan to reflect current wandering and elopement risk and person-centered interventions, including implementation of a one-to-one supervisor and providing redirection as needed when wandering behaviors occur.
• Complete an audit to evaluate each resident in the facility and identify residents who are at high risk for elopement.
• Review residents identified as high risk to ensure appropriate and effective elopement prevention measures are in place and documented in their care plans.
• Educate all staff members in all departments on resident-centered interventions for residents at high risk of elopement, the facility policy on reducing wandering and elopement risk, and reporting of any increased exit-seeking behaviors prior to working their next scheduled shift.
• Provide this education to new staff members during orientation.
• Educate the interdisciplinary team (IDT) on conducting root cause analyses of significant events to ensure appropriate actions are taken to prevent reoccurrence.
• Review the Elopement and Wandering Residents policy.
• Ensure progress notes for the prior 24 hours are reviewed each day for all residents during the clinical stand-up meeting to address any changes in behavior including wandering, exit seeking, or expressions of wanting to leave the facility.
• Address identified concerns through the IDT, including non-pharmacological interventions and a care plan review.
• Reevaluate residents by the IDT quarterly and any time increased exit-seeking symptoms are noted to ensure appropriate elopement prevention measures are in place and effective.
• Inform staff of any changes through in-servicing, care plan updates, and updates to the resident's Kardex.
• Audit new admissions for elopement risk and ensure appropriate interventions are in place.
• Conduct the new-admission elopement-risk audit daily for four weeks, then five times per week for four weeks, then three times per week for four weeks, and document it on an audit form.