F0689

J

Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Door Controls

Trinity, Florida Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a cognitively impaired resident who had been repeatedly identified as an elopement risk. The resident was admitted with diagnoses including unspecified dementia of unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, as well as cognitive communication deficit and a history of cerebral infarction, alcohol abuse with alcohol-induced anxiety disorder, and syncope and collapse. A quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and documented that the resident could ambulate 150 feet with supervision or touching assistance. The resident’s care plan included a focus area for risk of elopement, citing 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 via an electronic monitoring device, which had been initiated and then resolved prior to the incident. Elopement risk evaluations on multiple dates identified the resident as an elopement risk, and a prior physician order for a wander management bracelet had been in place but was discontinued before the elopement.

In the months leading up to the incident, facility records documented ongoing concerns about the resident’s wandering and exit‑seeking behaviors. A palliative care note recorded that the resident’s representative was concerned about the resident’s wandering and overall safety. Nursing and psychology notes described escalating behavioral concerns, agitation, combativeness secondary to confusion, not following safety instructions, and repeated attempts to leave the unit through an exit door. Staff documented periods of agitation and exit‑seeking in November and December, with multiple redirection attempts required to return the resident to his room. Despite these documented behaviors and repeated elopement risk evaluations, the resident did not have an electronic monitoring device in place at the time of the elopement, and the resident’s primary care physician stated he had not been informed of exit‑seeking behaviors or of the decision to remove the electronic monitoring device.

On the day of the elopement, staff last observed the resident around the nurses’ station and his room shortly before the incident. A CNA reported leaving the resident at the nurses’ station before going on break and, upon returning, was unable to locate him in his room or the building. A missing resident code was initiated, and staff began searching. The resident had exited from the second‑floor hallway near the maintenance office into a stairwell by holding the door handle for approximately 30 seconds, then proceeded down the stairs to a first‑floor door that opened to the outside without an alarm. From there, the resident walked through the parking lot and onto nearby roads, ultimately traveling approximately 0.6 miles away from the facility toward streets with posted speed limits of 30 mph and 55 mph. Multiple staff members reported not hearing any door alarms, and interviews revealed inconsistent staff understanding of how to identify elopement‑risk residents and who should be wearing electronic monitoring devices. The resident was missing for about 10 minutes without staff knowledge before being located off‑site by a CNA and returned to the facility, where he stated he had been going for a walk and that no one saw him leave. This failure to supervise and to ensure effective elopement prevention measures resulted in a determination of Immediate Jeopardy.

Additional interviews and record reviews highlighted gaps in staff awareness and communication related to elopement risk and monitoring systems. One CNA stated she was unsure how to identify residents at risk for elopement or who should be wearing an electronic monitoring device and did not know if any residents in the facility were at risk. The maintenance and housekeeping director stated that only the main lobby door was protected by the electronic monitoring device system and that other doors did not use these devices, while the regional nurse confirmed that the electronic monitoring device system only worked on the front door and would not have alerted at other exits. The nursing home administrator acknowledged that the resident had an elopement assessment upon admission and had previously worn an electronic monitoring device, but did not have one at the time of the incident, and that the door used to exit to the outside did not have an alarm. Staff accounts of the incident varied regarding the duration the resident was missing, but consistently indicated that no door alarms were heard and that the resident was found off facility grounds, damp from the rain, after the missing resident code was called. These documented actions and inactions formed the basis for the cited deficiency under the requirement to keep the environment free from accident hazards and to provide adequate supervision to prevent accidents.

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.
• Reviewed Resident #1's elopement risk and completed an updated elopement evaluation with plan of care updates as indicated.
• Interviewed Resident #1 upon return to the facility and evaluated the identified exit door used for proper function/alarm with no issues identified.
• Evaluated all facility internal exit doors for proper function with 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.
• Initiated education on the Missing Resident/Elopement Policy/Procedure (including elopement books) and Abuse/Neglect/Exploitation and completed education for all facility staff and contract therapy staff.
• Reviewed the prior 90 days of daily exit door checks to validate completion and 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 and completed new elopement evaluations with plan of care reviews/updates as indicated.
• Reviewed current residents with electronic monitoring devices to verify evaluation accuracy/appropriateness and proper orders/documentation and updated evaluation, order, and plan of care 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, implemented keypad/key fob exit function, and educated 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 to improve organization of the search and updated the location form to ensure all facility areas are assigned.
• Initiated ongoing competency testing related to resident elopement awareness and prevention (signs/symptoms of exit-seeking behavior, interventions, and notification) and completed testing for staff and contract therapy staff.
• Provided education to licensed staff on identifying elopement risk and locating electronic monitoring device status.