F0835

J

Failure of Administrative Oversight Leads to Undetected Elopement of Cognitively Impaired Resident

Fort Myers, Florida Survey Completed on 02-13-2026

Penalty

Fine: $17,675

Summary

Facility administration failed to provide effective oversight and implement processes to ensure resident safety related to unsafe wandering and elopement. A cognitively impaired, ambulatory, and confused resident with poor safety awareness exited the building through an unlocked front door after walking past an unattended front desk. The resident crossed a two-lane road and walked approximately half a mile over uneven terrain and near water ponds to a nearby college dormitory. Facility staff were unaware the resident had left until they were notified by college campus security about the resident’s transfer to a local emergency room via EMS.

The resident had multiple documented indicators of cognitive impairment and safety risk prior to the incident. The admission MDS showed moderately impaired cognition with a BIMS score of 12 and a need for partial to moderate assistance with ambulation and activities of daily living. Speech therapy documented moderate cognitive-communication deficits with problems in short-term memory, problem solving, and executive functioning. Nursing and provider notes described intermittent confusion, pulling out IV lines, statements indicating disorientation, and treatment-interfering behaviors requiring close supervision and safety monitoring. A psychiatric APRN documented that the resident lacked capacity to make healthcare and long-term placement decisions, was unable to understand the consequences of not receiving care, and recommended a guardian or POA. Despite this, the admission elopement assessment scored the resident as not at risk for elopement, there were no subsequent elopement reassessments, and the care plan, while noting impaired cognition, did not translate into effective elopement risk management.

After the resident left the facility unsupervised, the administration did not consider the event an elopement and did not document the incident or any measures to prevent further unsafe wandering in the clinical record. The Administrator characterized the event as the resident going out for a walk and failing to sign out, and stated the resident was cognitively intact based on a BIMS score obtained upon return, despite prior documentation of incapacity and dementia-level SLUMS scoring. The DON expressed a desire not to label the event as an elopement and acknowledged there was no documentation in the record about the incident, stating she did not want to enter a late note because the Administrator conducted the investigation. A Unit Manager LPN reported being told not to document anything and that the Administrator and DON would handle it. The facility had an elopement prevention policy defining elopement for incapacitated residents and requiring an elopement risk assessment, monitoring device, and care plan when such a resident wanders into an unsafe area or leaves the building, but these processes were not implemented for this resident. The lack of adequate supervision, failure to recognize and classify the event as an elopement, failure to reassess elopement risk, and failure to document the incident and related interventions led to a determination of Immediate Jeopardy under F835.

Removal Plan

• Resident #900 was successfully discharged home as planned.
• The Administrator/Designee completed staff re-education on Missing Resident Drill and Elopement with all staff members, emphasizing responding to door alarms, using the elopement binder, performing a resident headcount, and Administrator and DON notification.
• The Administrator/Designee completed Missing Resident Drills at varying times with staff members participating collectively from each department.
• The Administrator modified the receptionist process for residents exiting the facility and added this to education for newly hired staff, including use of a newly created binder with blue (supervision required) or white (safe for unsupervised LOA) sheets for each resident, requiring residents to sign in/out for LOA each time they leave, and opening the front door by remote or keypad.
• The facility’s contracted vendor removed the automatic open option on the front double doors so doors remain locked with access by staff remote or keypad entry/exit only.
• The facility extended receptionist hours and updated the front desk coverage process for breaks/step-away coverage and for after-hours coverage for LOA/visitors.
• The Chief Nursing Officer re-educated the Administrator and Director of Nursing on the CMS definition of elopement, their roles to ensure resident safety, and the expectation to complete a risk management report for elopement events.
• The facility changed its elopement policy to reflect CMS’s definition of elopement.
• The interdisciplinary team was re-educated on reporting and documenting resident incidents in the clinical record, the alleged deficient practice outlined on the immediate jeopardy template, and federal regulation F835, emphasizing adherence to medical record documentation policies and procedures.
• Residents admitted in the last 30 days were re-evaluated for accuracy of new admission assessments and documentation related to cognitive status and elopement risk.
• The receptionist on duty for the event was re-educated on ensuring residents exiting the facility were approved by clinical staff prior to allowing exit and on use of the LOA binder/blue-white sheets, sign in/out requirement, and door access by remote/keypad.
• The Director of Nursing/Designee completed new elopement risk assessments on all current residents in the EMR.
• All licensed nurses were educated on communicating physician determinations/changes in resident capacity to notify the DON and/or Administrator timely to ensure prompt re-evaluation of elopement risk.
• Staff were re-educated on the CMS definition of elopement, the updated elopement policy, documentation of resident incidents in the clinical record, and the new receptionist process for resident exits (including binder/blue-white sheets, clinical team determination of supervision for LOAs, sign in/out requirement, and door access by remote/keypad).
• An ADHOC QAPI meeting was held with the medical director participating by phone, and the QAPI committee approved the recommendations.
• QA meetings included review of the new receptionist process for residents exiting the facility.