F0689

D

Elopement From Secured Memory Unit Through Compromised Window

Delta, Colorado Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident at risk for elopement was free from accident hazards and adequately supervised, resulting in an elopement from a secured memory unit. The resident was younger than 65 and had severe cognitive impairment, with a BIMS score of 0/15, and documented wandering behaviors. His diagnoses included a history of traumatic brain injury, Wernicke’s encephalopathy, unspecified dementia with behavioral disturbance, alcohol-induced persisting dementia, delirium due to a physiological condition, and generalized epilepsy. His care plans documented a pattern of elopement attempts, a history of kicking out window screens, slamming windows in attempts to open them, and entering other residents’ rooms and bathrooms. He was identified as an elopement risk with impaired awareness of safety and a history of leaving his home unattended.

On the date of the incident, the facility’s investigation documented that the resident was last seen sleeping in his bed on the secured memory unit at 5:30 a.m. When staff checked on him at 6:02 a.m., he could not be located and was determined to be missing from the facility by 6:05 a.m. Staff initiated a search inside and outside the building and contacted the police. The resident was ultimately located off premises by law enforcement at 7:06 a.m., having been missing for approximately one to one and a half hours. The investigation determined that all door alarms were operable and no alarm had sounded, indicating the resident did not exit through a door.

The facility’s investigation concluded that the resident eloped by exiting through a window in an empty room on the secured unit and then leaving the secured courtyard. An open window was found with the screen replaced except for the unsecured bottom portion, and a broken safety stop was discovered on the window. The investigation documented that the resident opened the window, broke the safety stop, exited through the window into the courtyard, replaced the screen except at the bottom, and then climbed over the six-foot fence to leave the secure area. The resident’s personal items were later found on the backside of the fence near a tree in the courtyard, supporting this sequence of events. When the resident was returned to the facility, his oxygen saturation was 85% and his temperature was 96.4°F; he had an abrasion on his right elbow, reddened skin on both hands, and scratches on his hands and knees, and he was treated at the hospital for acute hypothermia. Additionally, review of the nursing progress notes did not identify documentation of the elopement event itself on that date.

Further observations and interviews showed that the resident continued to demonstrate exit-seeking behavior and attempts to open secured doors. On a later observation date, he was seen repeatedly pushing on emergency push bars at the back door of the memory care unit and attempting to open the main entrance door by pressing keypad buttons. Staff, including an RN, CNA, and activity assistant, attempted to redirect him with verbal cues, activities, and offers to walk with him. The facility’s wandering and elopement policy required identification of residents at risk for unsafe wandering and inclusion of strategies and interventions in the care plan to maintain safety. Despite the resident’s known history of elopement attempts, window-related behaviors, and impaired safety awareness, he was able to manipulate a window safety device, exit through the window, and leave the secured courtyard without triggering door alarms or being detected in time to prevent his elopement.