F0689

J

Failure to Prevent Elopement and Account for Cognitively Impaired Resident After Door Alarm

Lincolnshire, Illinois Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent the elopement of a cognitively impaired resident and to ensure that all residents were accounted for after a door alarm sounded. The resident had multiple diagnoses including dementia, altered mental status, anxiety disorder, unsteadiness on feet, malnutrition, alcohol abuse, pulmonary fibrosis, and a left femur fracture. An elopement risk assessment identified the resident as high risk for elopement, and the Minimum Data Set documented that the resident was not cognitively intact. CNA documentation on two dates in January showed elopement behaviors, and a nurse practitioner documented severe cognitive impairment and disorientation in late January and early February. The resident’s care plan noted cognitive impairment and multiple fall and safety risk factors, including poor safety awareness and dementia. Despite this, the resident’s picture was not included in the facility’s “Walkers” binder used to identify residents who wander.

On the night of the incident, staff reported that the resident was last seen in bed asleep between approximately 3:45 AM and 4:00 AM. The RN on duty stated that the main exit door alarm sounded around 3:00–3:20 AM; she turned off the alarm, looked outside, and did not see anyone, but did not notify the nursing supervisor on other units. She reported that a resident head count was performed after the alarm, but this was not communicated consistently, as the nursing supervisor stated she was never notified of an alarm and did not perform a head count on her units. Another CNA gave conflicting statements about whether she recalled an alarm and whether a head count was done, but confirmed that she believed all residents were present at that time. The facility’s policy on elopement and wandering residents states that alarms are not a replacement for necessary supervision, that staff must respond to alarms in a timely manner, and that a systematic approach to monitoring and managing residents at risk for elopement is required.

At approximately 5:42–5:43 AM, police responded to a 911 call from a passerby reporting a person in a wheelchair sitting outside in the cold. The police officer found the resident about a block away from the facility, in a wheelchair, wearing only a thin sweater with no winter gear, with a sweater on the ground nearby. The officer observed that the resident was very cold, shivering, had a shaky voice, smelled strongly of urine, and had wet pants in the groin area. The resident was disoriented, did not know where she lived or where she was going, and stated she had been outside all night. EMS arrived and documented cold exposure, chills, confusion, and cold skin, with an impression of hypothermia and emergent acuity. The resident was transported to the emergency department, where she was monitored and later documented to have a rectal temperature of 95.9°F at discharge. The police officer subsequently went to the facility and learned from staff that they had not known the resident had left the building until he informed them. He also reported that staff told him an exit door alarm had gone off around 3:30 AM but they were unable to confirm the cause, and he later observed wheelchair tracks in the snow near an employee exit door with an unshoveled sidewalk, suggesting a potential route of exit. These events demonstrate that the facility did not ensure adequate supervision and monitoring of a known high elopement-risk, cognitively impaired resident and did not effectively account for all residents after a door alarm sounded, resulting in the resident’s elopement and exposure to cold.

The Immediate Jeopardy was determined to have begun when the resident was found outside in the cold in her wheelchair by herself and was transferred to the hospital for cold exposure. The administrator was notified of the Immediate Jeopardy several days later. Interviews with nursing staff, the nursing supervisor, the police officer, and the resident, along with review of clinical records, EMS and hospital documentation, and facility policies, confirmed that the facility failed to follow its own elopement and wandering policy, failed to ensure that a high-risk resident was properly identified in the wandering binder, and failed to ensure that all residents were accounted for when an exit door alarm sounded. These failures led directly to the resident’s unsupervised exit from the facility and subsequent cold exposure.

The sidewalk route the resident likely used included broken and uneven concrete and led around the facility to a shopping plaza parking lot. The police officer believed the resident left near the employee exit door because the sidewalk there was not shoveled and he observed wheelchair markings in the snow. The resident later told EMS that she had been outside all night and had been living outside for a couple of months, although she had in fact been residing in the facility. When interviewed by the surveyor, the resident could not recall going outside in the cold or speaking with a police officer, and inaccurately reported that she went out the front door to smoke a couple of times a day, despite not having smoked since admission. These observations further illustrate the resident’s cognitive impairment and confusion at the time of the elopement and underscore the facility’s failure to provide adequate supervision and monitoring for a resident known to be at high risk for elopement.

Removal Plan

• All residents were reassessed for elopement risk.
• All residents identified as high risk for elopement had care plans reviewed for accuracy.
• Elopement binder reviewed and updated to reflect high risk residents.
• An emergency QAPI was held to review policies/procedures.
• Daily door alarm audits began.
• Door alarm added to interior door leading to staff entrance.
• Second door alarms added to reception door as well as the exit between two units in order to double alarm all exits.
• Additional speakers added so alarms are more audible.
• In-Service/Education was initiated on the facility's door alarm protocol, responding to alarms, and completing head counts.
• R1 was moved to a secured unit.
• The Administrator or designee will perform elopement risk assessment audits to ensure compliance with transfer protocols; findings will be reviewed during Quality Assurance and Performance Improvement meetings monthly; noncompliance will result in immediate corrective action and additional staff training; monitoring will continue until the QAPI committee determines sustained compliance has been achieved.
• The Administrator or designee will perform door alarm response audits to ensure compliance with transfer protocols; findings will be reviewed during Quality Assurance and Performance Improvement meetings monthly; noncompliance will result in immediate corrective action and additional staff training; monitoring will continue until the QAPI committee determines sustained compliance has been achieved.