F0689

J

Failure to Prevent Elopement of High-Risk Resident Despite Wander Guard and Known Exit-Seeking Behaviors

Saint Paul, Minnesota Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement appropriate, individualized interventions to prevent elopement for a resident who had been assessed as an elopement risk. The resident was admitted with diagnoses including repeated falls, dizziness and giddiness, unspecified mental disorder, and dementia with behavioral disturbance, and used a wheelchair. An elopement risk assessment identified the resident as an elopement risk due to verbal expressions of wanting to go home, wandering behavior, recent admission, and not accepting the situation. Suggested clinical actions included notifying staff of wandering and elopement risk, using exit alarms, and frequently monitoring the resident’s location. The care plan included a focus on wandering/elopement with goals that the resident would not leave the facility unattended and would remain safe, and interventions such as identifying de-escalation behaviors and providing reorientation. A nursing order directed staff to check the resident’s wander guard on the wrist daily and its function weekly.

In the days leading up to the elopement, multiple progress notes documented escalating exit-seeking and behavioral issues. Notes indicated the resident wanted to go back to a prior place, was wandering, attempting to elope, hitting staff, and looking for her husband. The resident was described as alert and oriented to self with confusion at baseline, with chronic disorientation, some confusion, and chronic short-term memory loss. Staff documented that the resident had been on one-to-one supervision on a previous shift after attempting to leave the facility and becoming aggressive when redirected. On the morning of the elopement, a progress note recorded that the resident came into the hallway undressed, kicking and cursing at staff. Staff interviews confirmed that the resident had previous exit-seeking behaviors, was not easy to redirect, would refuse care, and was often kept at the nursing station for increased supervision.

On the day of the elopement, staff assigned to the resident reported difficulty keeping track of residents during shift change and could not explain how the resident left the building while under their assignment. One NA stated the resident kept approaching the exit and setting off the wander guard alarm and that he had been assigned to watch the resident in the common area for a period before taking a break. At shift change, responsibility for watching the resident was to be handed off to other staff, but when the NA returned from break, the resident was missing. Another nurse reported that the resident had packed belongings and was waiting in the common area for transportation to another facility, and that around shift change staff left to find a replacement to supervise the resident; when they returned, the resident could not be located. Staff were unsure whether the wander guard alarm sounded, whether someone assisted the resident out the door, or how the resident exited the building, and the resident was still wearing the wander guard when later found. The facility’s location near several bus stations and the lack of camera coverage on the inside of the exit door were noted, and camera footage from outside showed the resident talking with other residents who were smoking and then following turkeys down a hill away from the building. The facility’s own policies required staff to attempt to prevent a resident’s departure if observed leaving and allowed use of a wander management system for residents at risk of elopement, but the events show that despite the resident’s known risk and documented behaviors, supervision and monitoring were not effectively maintained at the time of the elopement.

Removal Plan

• Facility began an investigation.
• Transferred R1 to a sister nursing facility with the capacity to keep her in a secured memory unit.
• Completed mandatory staff education on elopement, missing residents, facility policies and procedures, and the specific elopement event.
• Re-educated nursing staff on completing the elopement risk assessment accurately and completely.
• Checked the wander guard system and confirmed it was in working order for all residents identified as an elopement risk.
• Reviewed charts and care plans for other at-risk residents and added interventions as needed.