F0689

J

Failure to Implement Elopement Protections Allows Cognitively Impaired Resident to Exit Unnoticed

Southaven, Mississippi Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and implement its elopement prevention system for a resident identified as an elopement and wandering risk. The resident was admitted with diagnoses including unspecified moderate dementia with behavioral disturbance and wandering, and had a BIMS score of 0, indicating severe cognitive impairment. On admission, the resident was assessed as being at risk for elopement, and documentation noted that a wander guard was in place. The facility’s clinical care system guidelines required that residents at risk for elopement have individualized interventions documented on the care plan and caregiver guide, a photograph taken, and their information placed in a central elopement information system, such as an elopement book at the nurse’s station or reception.

On the day of the incident, nursing staff, including an LPN and CNAs, were aware that the resident wandered and was at risk for elopement and had last observed her walking the halls shortly after lunch. Around 1:00 PM, the LPN noticed the resident was no longer in the hallway and directed CNAs to check the resident’s room. When the resident was not found, the nurse initiated a missing resident code and staff began searching. Another resident reported seeing a lady in pink walking outside her window, prompting staff to search outside the building. The resident later confirmed in an interview that she had gone outside after following others because she did not want to be left alone when they left the table where she had been sitting.

At the front entrance, the receptionist allowed a visitor to exit while a woman in pink followed the visitor out. The receptionist stated she was not aware that this individual was a resident and did not know she was at risk for wandering or elopement. She reported that there was an elopement book at the desk that should contain pictures and information on residents at risk, but she had not been notified about this resident and there was no information about her in the book. The receptionist also stated that the door alarm did not sound when she let the visitor and the woman in pink out, and that the alarm had been intermittently activating earlier in the day without residents present. Maintenance later reported that video footage showed the receptionist turning off the alarm after the visitor and the resident exited. The administrator confirmed that her review of the video showed the receptionist turning off the alarm and verified that the elopement book did not contain a picture or information regarding the resident’s elopement risk at the time of exit. The resident was determined to have exited the facility at approximately 1:08 PM and was located by staff about 0.4 miles away at 1:33 PM.

Removal Plan

• Implemented the elopement guideline.
• Completed an immediate room-to-room audit of all residents to assure all were safe.
• Returned Resident #1 safely to her room.
• Checked Resident #1’s wander guard for functionality upon return and confirmed it was functioning as designed.
• Performed a full body audit/assessment of Resident #1 immediately upon return with no negative findings.
• Placed Resident #1 on 1:1 supervision pending psychiatric consultation.
• Placed a request for psychiatric consultation for Resident #1.
• Planned that following removal of 1:1 supervision, Resident #1 would have visual observations every 30 minutes for 24 hours and continued as needed.
• Reviewed and updated Resident #1’s plan of care to reflect elopement risk.
• Checked all doors for proper function and operation and confirmed all doors were functioning properly.
• Notified the Medical Director.
• Notified Resident #1’s resident representative.
• Completed a 100% audit of all residents identified for elopement risk to ensure placement and functioning of the wander guard system.
• Completed an audit of elopement books on all units and at reception to ensure pictures and care plans were present for all at-risk residents.
• Completed elopement drills on all shifts.
• Educated the Receptionist on elopement guidance with emphasis on prompt response and investigation of alarm activation.
• Placed the Receptionist on administrative leave.
• Initiated an in-service with nursing staff regarding elopement guidelines, including completion of risk assessments, care plan updates, and elopement book updates.
• Initiated additional staff education on elopement guidelines and abuse and neglect.
• Provided education to Social Services regarding elopement guideline oversight.
• Returned (DNS) to educate staff and monitor effectiveness.
• Educated House Supervisors and Managers on Duty regarding elopement book accuracy.
• Ensured no staff member will be permitted to work without completing education.
• Conducted a QAPI meeting to address root cause and corrective action.