F0689

J

Elopement of Dementia Resident Due to Inadequate Supervision and Exit Door Security

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a cognitively impaired resident with known wandering and elopement risk, who was able to leave the building without staff knowledge in subfreezing temperatures. The resident had dementia, a BIMS score indicating moderate cognitive impairment, poor decision-making skills, and documented behaviors and statements about leaving. An elopement risk evaluation identified the resident as ambulatory and at risk for elopement, and the care plan and physician orders specified use of a wander guard bracelet and supervision with a four-wheeled walker. Despite this, the quarterly MDS noted no wander/elopement alarm, and the resident’s care plan interventions were limited to redirection near doors and checking wander guard function per protocol.

On the night of the incident, nurse aide documentation recorded that the resident was observed sleeping in bed at approximately 1:00 AM and 3:00 AM. However, police-obtained video showed a person believed to be the resident outside at the back of the building at 1:50 AM, walking along the side of the building past the main entrance toward the road without a walker and with no apparent gait difficulty. A second video showed the same person at the driveway apron at 1:55 AM, then walking along the front sidewalk, slowing, bending down, and then falling face forward at approximately 1:58 AM, after which no further movement was observed. This timeline directly conflicted with the staff documentation that the resident was in bed at 3:00 AM.

Staff statements indicated that around 4:30–4:45 AM, a nurse aide discovered the resident was not in bed and began searching the unit with another aide. They searched rooms and another wing before notifying the RN supervisor at about 5:00 AM, approximately 30 minutes after the resident was first identified as missing. After the RN was notified, staff conducted another internal search and then began searching outside. Around 5:11–5:12 AM, staff found the resident lying on the sidewalk in front of the building, unresponsive or minimally responsive, cold to the touch, with clothing described as cold and icy. The resident was brought inside in a wheelchair, undressed, given dry clothing and warm blankets and towels, and assessed. Vital signs were severely abnormal, including a pulse in the 20s–30s and a thermometer reading "LO," indicating a temperature below 89.6°F. The RN reviewed the DNR status, contacted the Administrator and DON by conference call at approximately 6:08 AM, and 911 was not called until 6:23 AM, about 1 hour and 11 minutes after the resident was found outside.

The deficiency also includes multiple environmental and systems failures related to exit door security and elopement prevention. The facility had only one wander guard–equipped door (double fire doors near the nurse’s station leading to the lobby). Other exits near the resident’s unit and dietary area had no alarms to alert staff if residents passed through, and an outside door with a keypad had the access code posted above it. The alarm on that outside door was not audible in the adjacent hallway or at the nurse’s station. Observations showed that several exit doors (rear exit to back parking lot, kitchen exit near the hairdresser, and a T-wing exit to a courtyard) failed to latch or re-lock after being opened with the keypad code, and in some cases did not alarm or only briefly alarmed, allowing unrestricted entry and exit. A courtyard door from the dining room could be set with a code that left it unlocked for multiple entries/exits, and courtyard gates opened easily to the parking lot. The Director of Maintenance and Administrator acknowledged that keypad alarms had been turned off, that the code was improperly posted, and that doors were in "winter mode" with no functioning alarm notification to staff, and the facility lacked a policy to ensure proper functioning of emergency exit doors.

Additional residents were also identified as elopement risks, with dementia, cognitive impairment, and wandering behaviors, and had orders or care plans for wander guards and checks of device function and placement. One resident’s MDS showed no wander/elopement alarm despite elopement risk, and another had a care plan for elopement risk with interventions to check wander guard function and placement every shift. These findings, combined with the malfunctioning and non-alarming exit doors, the posted keypad code, and the lack of audible alarms to the nurse’s station, demonstrate that residents at risk for elopement could exit the building or enclosed areas without staff awareness. The facility’s own leadership acknowledged that the resident should not have been able to exit without staff knowledge, that nurse aides should have notified the nurse immediately when the resident was found missing, and that 911 should have been called immediately after the resident was found outside.