F0689

J

Failure to Prevent Elopement of Two High-Risk Residents From Secured Alzheimer’s Unit

Philadelphia, Mississippi Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and maintain a secure environment for residents identified as at risk for elopement and wandering on a locked Alzheimer’s unit. Two residents with severe cognitive impairment, both assessed with high elopement risk scores of 95, were able to exit the secured unit and the facility without appropriate staff detection or intervention. The facility’s own policy stated that residents who exhibit wandering behavior or are at risk for elopement would receive adequate supervision and care in accordance with their person-centered care plans, but this did not occur for these residents.

On the day of the incident, a door alarm to the exit leading from the Alzheimer’s unit into an enclosed courtyard sounded at approximately 1:32–1:35 PM. Staff responded to the alarm, but the responding staff member did not see any residents in the courtyard and silenced the alarm. At that time, one resident had entered the door code, opened the door, and exited the unit with another resident. Staff interviews revealed that the two residents had last been seen leaving the dining area around 1:00 PM, and one CNA went on break shortly thereafter, returning a little after 1:30 PM to find the door alarm sounding. Despite the alarm and staff response, no one identified that the two at-risk residents had left the unit.

Subsequently, one of the residents was observed outside on facility property at approximately 1:48 PM and was brought back inside by staff, who then discovered that the other resident was missing during a head count at approximately 1:52 PM. Interviews and the facility’s investigation showed that the missing resident had obtained or knew the door code and used it to leave the locked unit, then left the facility grounds and traveled off-site. The resident later reported that he knew the code and used it to exit because he wanted to go home, and another resident confirmed that he had opened the door and let him outside. Staff also acknowledged that door codes had been given to family and visitors in the past so they could enter and exit the unit, which contributed to the resident’s ability to obtain and use the code to leave the secured area undetected.

The missing resident, who had diagnoses including cerebral infarct and schizophrenia and a BIMS score indicating severe cognitive impairment, was not located on the unit or facility property during the search. Law enforcement and the resident’s responsible party were notified, and it was determined through phone contact and law enforcement assistance that the resident had already been picked up in a vehicle and transported away from the facility. The resident was ultimately located by deputies in another county at his home address and returned to the facility later that afternoon. During this time, the resident remained unsupervised away from the facility, despite his known elopement risk and cognitive impairment, demonstrating a failure to ensure adequate supervision and secure exit controls for residents at risk for elopement.

The survey agency determined that this failure to supervise and prevent elopement for residents identified as elopement and wandering risks constituted noncompliance with 42 CFR 483.25(d)(1)(2) (F689 – Free of Accident Hazards/Supervision/Devices) at a Scope and Severity level J, representing Immediate Jeopardy and Substandard Quality of Care. The Immediate Jeopardy and Substandard Quality of Care were determined to have begun on the date of the elopement event and were later classified as Past Non-Compliance based on the facility’s subsequent actions, but the deficiency itself centered on the initial failure to prevent the residents’ unsupervised exit from the secured unit and facility.

Removal Plan

• Recovered Resident #2 and returned him to the unit; placed Resident #2 on one-to-one monitoring to ensure safety.
• Performed a resident head count on the unit to account for all residents.
• Initiated Code Yellow (missing resident).
• Notified facility administration and law enforcement.
• Initiated a multi-facility property search by all departments of the nursing home and hospital.
• Obtained Resident #1’s cell phone number from the responsible party and called the resident; coordinated with law enforcement to ping the cell phone location.
• Assessed Resident #1 upon return for distress/injury and placed Resident #1 on one-to-one monitoring to ensure safety.
• Notified the Mississippi State Department of Health via hotline.
• Changed all exit door codes to the Alzheimer’s unit to secure the unit.
• Initiated Elopement and Wandering in-service with all staff; required completion before staff could work.
• Reviewed Elopement and Wandering Resident policies.
• Reviewed all Alzheimer’s Unit residents’ elopement care plans.
• Obtained and installed a doorbell on the unit to allow visitors to call for access; eliminated visitor access to unit door codes.
• Held a post-elopement event review/QA meeting to review safety measures and ongoing monitoring.
• Installed a safety alarm on the courtyard exit gate to notify staff when the gate is ajar.
• Initiated safety alarm checks every shift to ensure doors are closed and alarms function properly.
• Changed Resident #1 to every fifteen-minute checks.
• Ordered badge access for all entry/exit doors on the Alzheimer’s unit.
• Submitted a written investigation report to the Mississippi State Department of Health.
• Scheduled activity staff for increased monitoring and activities on the Alzheimer’s unit.
• Placed Resident #1 on one-to-one monitoring for increased exit-seeking behaviors.
• Installed live-view cameras with a screen at the nurses’ station for increased supervision of all entrance/exit doors to the Alzheimer’s unit.
• Ordered hallway mirrors for increased visualization of hallways and exit doors.
• Held a follow-up QA meeting to discuss the ongoing elopement plan, effectiveness, and monitoring.