F0689

J

Failure to Supervise Leads to Undetected Resident Elopement in Cold Weather

Beverly Hills, Michigan Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision to prevent a resident with severe mental illness and a history of homelessness and frostbite from exiting the building without staff knowledge. The resident had diagnoses including paranoid schizophrenia, adjustment disorder, unspecified psychological development disorder, insomnia, malnutrition, unsheltered homelessness, hyperlipidemia, and bilateral toe amputations due to prior frostbite and gangrene. An MDS assessment documented moderate cognitive impairment and independence with mobility. The resident had a history of behavioral issues toward staff, such as hitting self, tearing items, urinating in garbage cans, removing bed sheets, screaming at staff, and throwing water on the floor. The resident had previously been assessed as an elopement risk from 2/14/24 to 1/25/25, but after 1/25/25 was no longer assessed as an elopement risk. A community mental health assessment documented that the resident’s mental illness was severe, interfered with self-care, and that due to severe mental illness and chronic homelessness, the resident needed to remain in the facility for long-term care.

On the evening and night prior to the elopement, the resident consumed 100% of an evening snack at 7:28 PM and received scheduled bedtime medications at approximately 10:15 PM. Around 12:30 AM, the resident was observed by multiple staff members in the dining room and later ambulating toward the room, with staff reporting no distress, agitation, or expressed desire to leave. A CNA reported seeing the resident in the room around midnight to 12:30 AM while pulling garbage and did not return for the remainder of the shift. The night RN reported last seeing the resident in the room at about 12:30 AM and did not check again for the rest of the shift, despite stating that the standard of care was to check residents every two hours. Both the RN and CNA cited the resident’s history of aggression and refusal to allow staff into the room as reasons they did not perform further checks. The day-shift RN later inaccurately documented that the resident refused morning medications and initially told the Administrator and police that the resident had been seen at 2:00 AM, which was later acknowledged as untrue when police records showed the resident had already been picked up off premises by that time.

Police documentation showed that the resident had exited the building before 1:33 AM and was encountered walking down the road, stating an intention to go to a casino. Law enforcement transported the resident to a heated bus shelter and left the resident there shortly after 1:33 AM. The facility did not become aware that the resident was missing until approximately 2:00 PM, when staff attempted to escort the resident for a customary smoke break and could not locate the resident. A house-wide sweep and full census head count confirmed all other residents were accounted for, and the facility’s Missing Resident Procedure was then activated. During a later hospital interview, the resident stated that he left because he was upset about his shoes and reported exiting through a dining room window, saying he manipulated the window to open and closed it behind him. The Administrator reported that there were footprints in the snow outside the window, although the window’s side panels were mechanically limited to open only four to five inches. The Administrator acknowledged uncertainty about the exact route of exit but confirmed that no door alarms were reported as activated and that the facility did not use video surveillance. The facility’s own root cause analysis identified a breakdown in consistent resident supervision, specifically the failure to complete purposeful rounding and timely checks on the resident, which delayed recognition of the resident’s absence for approximately 13 hours.

Removal Plan

• Completed a full-house head count confirming all other residents were accounted for and safe.
• Implemented one-to-one monitoring at the primary exit.
• Maintained one-to-one monitoring until door codes were changed and the door push-button was disabled.
• Completed elopement risk assessments on all residents and updated care plans as indicated.
• Suspended involved staff pending investigation.
• Implemented mandatory purposeful rounding with nurses and CNAs.
• Implemented CNA walking rounds and shift-to-shift handoff documentation reviewed by charge nurses.
• Completed facility-wide education on elopement prevention, supervision expectations, abuse and neglect prevention, shift-to-shift reporting and rounding, purposeful rounding, and documentation integrity.
• Provided the same education to staff not present on the education date on their next scheduled workday.