F0689

D

Failure to Prevent Elopement of Cognitively Impaired Resident from Secured Courtyard

Palisade, Colorado Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent the elopement of a resident identified as an elopement risk, resulting in the resident leaving the secured unit courtyard and facility grounds without staff knowledge. The resident was an older adult with diagnoses including unspecified dementia with mood disturbance, major depressive disorder, and a history of Hodgkin’s lymphoma. A recent MDS assessment documented moderate cognitive impairment with a BIMS score of 10/15, independence with mobility, and wandering behaviors. Nursing and behavior notes over several months documented that the resident frequently talked about leaving the facility, wanting to jump the fence and run, hitchhike or take a bus home, and return to his property, as well as an incident where he attempted to exit through the front door by shoving and kicking it.

The resident’s care plan identified him as an elopement risk related to dementia and noted specific triggering words for wandering or eloping, such as “guardian” and “conservator.” Interventions included identifying patterns of wandering, providing structured activities and reorientation, and, as of a later revision, having a staff member with the resident at all times when he was outside in the courtyard due to his risk of jumping the fence. Prior to the elopement, documentation showed that the resident had been observed standing on a metal pathway railing in the secured unit courtyard and looking over the wooden fence into the adjacent smoker’s courtyard. Staff notes indicated he was encouraged not to stand on the railing, but this observation was not escalated to the NHA or unit manager, who later stated they were unaware of this behavior. Staff interviews revealed that when the resident went outside to the courtyard, staff generally checked on him every 10–15 minutes by peeking or glancing outside, without a formal schedule.

On the day of the elopement, the resident was allowed to go alone into the secured unit courtyard to de-escalate after being agitated. The NHA reported that staff customarily obtained only a quick visual confirmation when he was outside because he was sometimes not accepting of staff staying with him. That morning, staff were occupied serving breakfast to other residents and did not check on him as frequently as usual. A nurse last saw him in the secured courtyard at approximately 8:30 a.m., and a new nurse on the general population side later saw him in the smoker’s courtyard but did not recognize that he was a secured unit resident who should not be in that area. The resident subsequently left the property by climbing over the fence line, which included a wooden fence shared between the secured and smoking courtyards and a chain link/wire fence beyond. He encountered a police officer, requested to be taken closer to his home, and was dropped off at a gas station in a neighboring town before being located and returned to the facility. The facility’s investigation concluded that the resident likely used the metal railing in the secured courtyard to climb over the fence, and that there were no other access points that would have allowed his exit.