F0600

J

Failure to Respond to Exit Alarm and Supervise High-Risk Resident Resulting in Elopement and Injury

Bradenton, Florida Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident from neglect by not responding appropriately to an exit door alarm and not providing adequate supervision to prevent elopement. The resident had diagnoses including dementia, psychotic disorder with hallucinations, depression, delusional disorder, falls, muscle weakness, and lack of coordination. A recent MDS showed a BIMS score of 6, indicating severe cognitive impairment, and progress notes documented wandering, impulsivity, agitation, difficulty with redirection, and concern for safety. The resident had been assessed as at risk for elopement, with an elopement risk score of 19 on admission (≥12 indicating risk) and a subsequent score of 10, and the care plan identified elopement risk related to cognitive impairment with interventions such as notifying other departments of elopement risk and using verbal cues and distraction techniques.

On the night of the incident, the resident was last seen by the assigned CNA around 2:30 a.m. in bed asleep. Shortly thereafter, an emergency stairwell exit door alarm by the therapy department sounded. Video footage later reviewed by the Director of Plant Operations showed the resident, without a walker or wheelchair, walking down the therapy hallway holding the railing, leaning on the stairwell door at approximately 2:32 a.m., triggering the alarm and the audible message “Exit now, exit now,” and then opening and closing the door. The resident then descended two flights of stairs and exited the building through another alarmed door to the outside, all unwitnessed by staff. The stairwell and exterior areas had no cameras, and no staff were observed responding to the alarm during at least 20 minutes of reviewed footage.

Multiple staff heard or were informed of the alarm but did not initiate the facility’s elopement procedures. The supervising LPN on duty, who was on the second floor when the alarm first sounded, attempted to silence the alarm but could not recall the code and assumed the alarm was malfunctioning. She contacted maintenance for assistance and then returned to other tasks on the first floor without initiating a search, checking outside, or calling a code for a head count. The assigned CNA was on break when the alarm sounded, received a call from the supervisor about the alarm, and believed it was another malfunction similar to a prior event; he did not check on his residents when he returned from break and recalled the alarm still sounding. The LPN assigned to the resident heard an unfamiliar alarm but did not recognize its source, did not immediately verify resident whereabouts, and reported not having been trained on elopement drills or the sound of the door alarms. Other staff on the first floor either did not hear the alarm or were told by the supervisor that it was a malfunction. During this time, the resident left the facility, walked through the parking lot, crossed a four-lane road, and entered a neighborhood where he fell, sustaining a left forehead laceration and left elbow skin tear, and was eventually found outside, wet and shivering in the rain, by local law enforcement and transported to the hospital. The facility did not become aware of the resident’s absence until notified by law enforcement, and the resident had been missing for approximately two hours without staff knowledge, leading surveyors to determine Immediate Jeopardy related to neglect and failure to prevent elopement.

Interviews with clinical providers further underscored the resident’s known risks. The nurse practitioner and physician described the resident as having advanced dementia, confusion, cognitive dysfunction, impulsivity, restlessness, difficulty with redirection, shuffling gait, and muscle weakness, with a history of expressing a desire to go home and requiring assistance with ambulation using a walker. Staff nurses and CNAs reported that the resident frequently wandered, was extremely confused, constantly tried to get up, was unsteady on his feet, and required frequent redirection, with some staff stating he should have been on 1:1 supervision or 15-minute checks due to his behaviors and fall risk. Despite these known risks and the existing care plan identifying elopement risk, staff did not implement effective supervision or appropriate responses to the door alarm on the night of the incident, resulting in the resident’s unwitnessed elopement and injury.

Removal Plan

• Implemented 1:1 supervision with staff at all times for Resident #2 due to elopement risk.
• Implemented an order that Resident #2 may only go out on leave of absence (LOA) with a responsible party.
• Updated Resident #2 care plan to include family assisting with placement to a secured unit.
• Updated Resident #2 care plan to include providing the resident with a 1:1 companion as needed to decrease risk of exit seeking.
• Provided education to the assigned nursing supervisor and assigned nurse regarding responding to alarming doors, searching immediate surroundings, completing a head count when doors alarm, and timely DON notification of elopement.
• Suspended the nurse supervisor and assigned CNA pending investigation.
• Held an ad hoc QA meeting regarding elopement with the Administrator, DON, ADON, VP of Clinical Operations, and Medical Director.
• Conducted ongoing QAPI discussions focused on response to alarming doors, elopement drills, head counts, and prevention of neglect related to elopement.
• Provided education to the DON, ADON, and Administrator regarding the elopement, affected policies, alarming doors, head counts, risk management reports, reporting to AHCA, elopement drills/audits, QAPI, hourly head count, investigation guidance, and ongoing education/monitoring.
• In-serviced department heads on responding to alarming doors and checking surrounding areas to visually ensure the area is secure.
• Initiated abuse and neglect policy education with all current staff, emphasizing neglect, maintaining a safe environment, and required actions when a door alarm sounds.
• In-serviced assigned staff on responding to alarming doors, checking surrounding areas, performing a head count, and neglect/elopement prevention and response.
• Conducted elopement drills on every shift, then implemented random weekly drills performed by DON/ADON/designee.
• Started elopement education audits, then transitioned to random-shift audits performed by DON/ADON/designee.
• Completed elopement risk reassessments for all residents by ADON, clinical unit managers, and DON.
• Reviewed care plans for residents at risk for elopement by DON.
• Reviewed the elopement binder for accuracy by DON.
• Audited all current residents' LOA orders in the electronic health system by DON, ADON, and unit managers.
• Performed routine door monitor/alarm function checks at all exit doors by the Director of Maintenance.
• Tested exit alarms by a third-party independent contractor.
• Updated the CE-4 Elopement Prevention Policy; reviewed with the IDT in ad hoc QAPI and re-issued to all departments with education provisions.
• In-serviced current staff on the updated CE-4 Elopement Prevention Policy.
• Implemented emergency in-servicing education that all alarming doors must be treated as potential resident elopement and require a head count, and that only maintenance can identify a malfunctioning door alarm.