F0600

J

Failure to Prevent Elopement of High-Risk Resident and Respond to Exit Door Alarms

Trinity, Florida Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from neglect by not responding to an exit door alarm and not providing adequate supervision to prevent an elopement. On the day of the incident, a CNA left the resident at the nurse’s station around 1:45 p.m. to go on lunch break. The resident, who had a history of exit-seeking and wandering behaviors, was later discovered missing from his room at approximately 2:15 p.m. A facility-wide missing resident code was initiated, and staff began searching the building and surrounding area. Multiple staff members reported they did not hear any door alarms at the time of the elopement.

The resident had been admitted with diagnoses including unspecified sequelae of cerebral infarction, alcohol abuse with alcohol-induced anxiety disorder, unspecified dementia with moderate cognitive impairment, cognitive communication deficit, and syncope and collapse. His most recent MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and he was able to ambulate 150 feet with supervision or touching assistance. The care plan identified him as at risk for elopement due to exit-seeking behavior and ambulating without assistance in hallways, with interventions such as diversional activities, frequent visual checks, and use of an audible monitoring system. Elopement risk evaluations on multiple dates had identified him as an elopement risk, and prior progress notes documented escalating behavioral concerns, repeated attempts to leave through exit doors, agitation, combativeness, and exit-seeking behaviors.

Despite this history, the resident did not have an electronic monitoring device in place at the time of the incident, and the prior intervention to use an audible monitoring system had been resolved. The resident exited from a second-floor hallway door near the maintenance office into a stairwell, holding the door handle for approximately 30 seconds to open the delayed egress door, then proceeded down the stairs to a first-floor exit door that had no alarm and could be opened freely from the inside. He then exited through another alarmed door near the business office to the parking lot, but staff reported not hearing any alarms. The resident walked through the parking lot and onto nearby roads, ultimately being found approximately 0.6 miles from the facility by a CNA who left in her car to search for him. Interviews revealed inconsistent staff understanding of which residents were at elopement risk and who should be wearing electronic monitoring devices, with at least one CNA stating she was unsure how to identify elopement-risk residents or whether any such residents were currently in the facility. The facility’s failure to supervise the resident adequately and to ensure effective functioning and response to exit door alarms resulted in an elopement that surveyors determined created a likelihood for serious injury and/or death and was cited at Immediate Jeopardy.

Additional interviews highlighted gaps in communication and assessment related to the resident’s elopement risk. The Nursing Home Administrator stated that the resident did not exhibit wandering and exiting behaviors prior to the incident, despite documentation of prior exit-seeking and agitation. The resident’s primary care physician described him as having cognitive decline with variable mentation and stated that if the facility decided to remove the electronic monitoring device, this should have been communicated to him; he also reported he had not been informed of any exit-seeking behaviors. Some staff, including an LPN and CNAs, acknowledged that the resident had shown exit-seeking behaviors in November and December, and one CNA stated that if staff had known more, they might have been more aware of the need to continue monitoring for elopement risk. The combination of the resident’s known elopement risk, removal of monitoring interventions, lack of staff awareness, and failure to respond to or detect door alarms led directly to the resident’s unsupervised departure from the facility.

Removal Plan

• Implemented 1:1 enhanced monitoring for Resident #1 upon return to the facility until discharge
• Updated Resident #1’s care plan
• Completed a PTSD evaluation for Resident #1 with no concerns identified
• Reviewed Resident #1’s elopement risk status; completed an updated elopement evaluation and updated the plan of care as indicated
• Interviewed Resident #1 upon return to the facility; resident described the path taken and what occurred to the NHA/DON
• Evaluated the identified exit door used to leave the unit for proper function and alarm; no issues identified
• Evaluated all facility internal exit doors for proper function; no issues identified
• Completed education on doors and alarms for 100% of staff
• Placed temporary auditory sensor alarms at identified secondary doors that exit the facility
• Held an Ad Hoc QAPI committee meeting to review the concern, approve corrective interventions, and approve a PIP
• Initiated mock elopement drills (every shift for one week, then daily for one week, then every other day ongoing per QAPI recommendations)
• Initiated education on the Missing Resident/Elopement policy/procedure (including elopement books) and Abuse/Neglect/Exploitation; educated all facility staff and contract therapy staff
• Reviewed records of previous daily exit door checks for the past 90 days to validate completion; continued daily door checks per QAPI direction
• Reviewed elopement books to ensure proper information is in place and books are easily accessible
• Verified functioning of the electronic monitoring device check machine
• Evaluated current residents for elopement risk; completed new elopement evaluations and reviewed/updated care plans as indicated
• Reviewed current residents with electronic monitoring devices to verify evaluation accuracy/appropriateness, proper orders, and documentation for placement; updated evaluation/order/care plan as indicated
• Checked the electronic monitoring device system at the front door and confirmed it was functioning
• Held a follow-up Ad Hoc committee meeting to review actions/interventions/outcomes and approve PIP items; Medical Director participated
• Educated direct care licensed nursing staff on completion of elopement evaluations
• Verified proper functioning of exit doors and alarms by the regional maintenance consultant
• Converted locked exit doors to remove delayed egress; exit doors now require key fob/keypad for exiting; educated all facility staff and contract therapy staff
• Educated direct care licensed nursing staff on interventions and notification for residents who refuse/remove wander guard device
• Verified resident photos and resident room name door tags for identification/verification and updated as indicated
• Held an Ad Hoc committee meeting to review steps taken and approve PIP item completion
• Held an Ad Hoc committee meeting; reviewed and updated the elopement drill tracking form/process and updated the location form to ensure all facility areas are assigned
• Initiated ongoing competency testing on resident elopement awareness and prevention (signs/symptoms of exit-seeking behavior, interventions, and notification); completed for facility staff and contract therapy staff
• Provided education to licensed staff regarding identifying elopement risk and locating electronic monitoring device status