F0600

J

Failure to Follow Elopement and Emergency Response Policies for Missing, Unresponsive Resident

Windsor Locks, Connecticut Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident at risk for elopement by not following its elopement and change in condition policies. The resident had dementia, an elopement evaluation identifying them as at risk for elopement, and a care plan including a wander guard on the right ankle with interventions to redirect the resident near doors and check the wander guard per protocol. A quarterly MDS showed moderate cognitive impairment, independent ambulation with supervision, and no wander/elopement alarm. Nurse aide documentation showed the resident was observed sleeping in bed at approximately 1:00 AM and 3:00 AM.

According to staff statements, around 4:30 AM a nurse aide noted the resident was no longer in bed and began searching other rooms and another wing, informing a coworker who also searched while the aide went outside. The coworker then notified the nurse. The two aides searched outside and found the resident lying on the ground by the walkway. The nurse was notified, and the resident was brought back inside. RN documentation and interviews indicated the RN was informed at approximately 5:00 AM that the resident was missing, initiated another room search, then an outside search, and the resident was found on the sidewalk outside, only responding to painful stimuli and blinking. The facility’s elopement policy required that when a resident is discovered missing, the supervisor or DNS be informed, an overhead page be made, staff conduct repeated searches including outside, and the police be notified within 15 minutes if the resident was not located; staff interviews indicated the police should have been notified within 15 minutes of not locating the resident.

After the resident was found outside in below-freezing temperatures and brought back inside, staff applied warm clothing and blankets. The RN reviewed the resident’s code status, assessed the resident, and contacted the DNS and Administrator before calling 911. The thermometer used to assess the resident read “LO,” consistent with a temperature below 89.6°F. EMS records showed 911 was called at 6:23 AM, EMS arrived to find the resident unresponsive, pulseless, apneic, extremely cold to the touch, with lividity noted on the left side and fixed, non-reactive pupils, and the resident was pronounced deceased at 6:46 AM. The facility’s change in condition policy directed that 911 should be called immediately if a resident is unresponsive. The facility failed to notify police within 15 minutes of the resident being identified as missing and failed to call 911 immediately when the resident was found unresponsive outside in severe cold, resulting in a finding of Immediate Jeopardy.