F0689

J

Failure to Supervise Confused Resident and Respond to Exit Alarms Resulting in Elopement and Injury

Eureka, Illinois Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and prevent an intermittently confused resident from exiting the building through alarmed doors without staff knowledge. The resident had multiple diagnoses including Parkinson’s disease, polyneuropathy, repeated falls, weakness, gait and mobility abnormalities, heart failure, sepsis, pneumonia, and type 2 diabetes. Clinical documentation at admission and shortly thereafter described the resident as confused or chronically confused, and a nurse practitioner note documented disorientation to time. Nursing staff and the resident’s spouse reported that the resident had periods of confusion, agitation, restlessness, wandering in a wheelchair, and repeated statements about wanting to go home. On the day of the incident, staff documented that the resident was exit seeking and upset, and the spouse reported that the resident had tried to get out the door and frequently stated he wanted to go home.

Despite these behaviors and documented intermittent confusion, the resident was not identified as an elopement risk on admission, did not have a wandering alert bracelet in place at the time of the incident, and was not placed on 1:1 supervision or increased monitoring. The ADON stated that the resident’s BIMS score indicated cognitive intactness and that he was therefore determined not to be at risk for elopement, even though licensed staff notes documented confusion. The day-shift LPN reported that during shift change she had to turn the resident’s wheelchair around at the front door because he was trying to leave, and she passed on to the oncoming nurse that the resident was agitated. The evening LPN acknowledged knowing the resident was intermittently confused, very agitated, fixated on needing to be somewhere, and repeatedly going to the front door. He administered lorazepam for agitation but left the resident in the lobby in a wheelchair, did not initiate 1:1 supervision, and did not instruct the assigned CNA to increase supervision.

The facility also failed to effectively monitor and control its door alarm system. The front entrance had two doors with alarms and a keypad code, and multiple staff, including the administrator, ADON, CNA, maintenance director, and social services director, confirmed that most family members and visitors had been given the door code so they could enter and exit freely. The administrator’s review of camera footage showed the resident opening the inner and outer front doors, triggering the alarm, which sounded for several minutes until a visitor entered the code and silenced it; no staff responded to the alarm, no Code Yellow was called, and no head count was performed. A police officer on patrol later found the resident outside in the facility parking lot next to an overturned wheelchair, in cold, snowy conditions, wearing only a thin T‑shirt and sweatpants, with bleeding lacerations and contusions. Facility staff confirmed they were unaware the resident had left the building until alerted by the CNA who encountered the police officer and the injured resident outside. The facility administrator stated she did not consider the resident’s leaving the building to be an elopement and did not report the incident to the state regional office. These failures resulted in an Immediate Jeopardy determination beginning on the date of the elopement.

The survey findings further documented that staff practices and visitor access to door codes undermined the facility’s elopement prevention systems. A CNA stated that when the front door alarm sounded, she turned off the alarm, and during the survey a visitor was observed entering the sounding front door alarm by using the keypad code. The ADON and maintenance director confirmed that family members were routinely given the code, and that entering the code when an alarm was sounding would both unlock the door and silence the alarm. The administrator acknowledged that on the night of the incident, no staff responded to the alarm that sounded for several minutes, and that a CNA was seen on video leaving through the same front door shortly after the alarm was silenced. The resident’s spouse reported that she had informed staff of the resident’s confusion and need for close supervision, had observed him trying to get out the door, and was told the facility could not provide one‑to‑one care. She also stated that when she later asked why the resident did not have a wandering alert bracelet before he left the facility unattended, the administrator responded that in hindsight he should have had an alarm on. The combination of not recognizing the resident’s elopement risk, not implementing appropriate interventions, and allowing visitors to silence exit alarms without staff verification led directly to the resident’s unsupervised exit and subsequent injury.

Removal Plan

• Resident was placed on facility's elopement program with placement of a wander alert bracelet.
• Elopement assessment and care plan were updated to reflect the resident's risk for wandering/elopement by social service director/DON/designee.
• A facility-wide elopement audit using the elopement assessment in PCC was conducted by the Social Service Director.
• All exterior door codes were changed by the facility Maintenance Director.
• All employees were in-serviced by all department managers on the elopement and wandering residents and accidents and supervision policy, including that only employees are to have door codes.
• Care plans were reviewed and updated as needed for residents at risk for elopement by social service director/DON/designee.
• The elopement policy was reviewed by administrator/regional nurse consultant/DON.
• DON will review all new admissions to monitor that all interventions are in place for residents at risk for elopement.
• As part of orientation, new hires will receive education on wandering, elopement, and safety by social service director/DON/designee.
• All department managers were in-serviced by the administrator on the elopement and wandering residents and accidents and supervision policy.
• All employees were in-serviced by their department managers on the elopement and wandering residents and accidents and supervision policy, including that only employees are to have door codes.
• Employees are to assist all visitors in and out of the facility to ensure resident safety.
• Wander alert bracelets were placed in the narcotic drawer and nurses were in-serviced by the DON.
• Nurses were educated on how to place wander alert bracelets on residents.
• The DON/designee will be informed regarding wander alert bracelet placement and use.
• QAPI policy and improvement processes will be used to review and interpret all audit findings.
• All findings will be discussed at monthly QAA for a minimum of 3 months or until the facility is compliant.
• DON/designee will audit 3 times a week for 1 month then weekly for 2 months using the elopement assessment.
• Residents at risk for elopement will be reviewed and a wander alert bracelet applied, care plan updated, doctor orders obtained, and placed in the elopement binder by social service director/DON/designee.
• IDT will review high risk residents who are at risk for wandering and/or elopement during morning meeting.
• All new admissions and readmissions will be reassessed for wandering and risk for elopement and the plan of care updated as needed by social service director/DON/designee.
• Social Service Director will maintain the elopement binder and update care plan with all new interventions.
• Monitoring of all residents for statements such as 'I want to go home' or other expressions indicating a desire or need to leave will be conducted by nurses/social service director/DON/designee.