F0689

J

Failure to Supervise High-Risk Resident Leading to Unrecognized Elopement

Saint Louis, Missouri Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident with a known history of elopement from prior facilities received adequate supervision and monitoring, resulting in the resident’s absence from the facility going unrecognized for at least 4.5 hours. The resident had diagnoses including schizoaffective disorder, bipolar type, lack of coordination, and muscle weakness, and had a legal guardian. The resident’s care plan identified a problem of elopement risk due to a history of elopement from a prior secure facility, with an intervention for face checks/intensive monitoring per facility protocol. Despite this, the resident’s elopement assessments on two prior dates scored the resident as not at risk for elopement, and no additional elopement risk assessment was completed after the guardian requested that the resident be moved to a secured unit because of prior elopements and recent marijuana use at the facility.

On the day of the incident, the resident’s room was located adjacent to an exit door at the end of a hall. Staff accounts showed that the resident was last definitively seen by an LPN between approximately 2:00 P.M. and 2:30 P.M. The resident did not come out to smoke at 11:45 A.M., and later did not come for dinner. Instead of personally checking on the resident, the LPN sent another resident to the room; that resident reported back that the missing resident did not want to be bothered and was asleep, and the LPN did not verify this information before leaving at shift change. The oncoming LPN reported that when the shift began at 7:00 P.M., the resident was already not in the facility, and a CNA informed the oncoming nurse that the resident had not been seen, prompting a search and a code white. The oncoming LPN stated they were unaware of any elopement history for the resident and had not been told the resident might leave.

Additional documentation and interviews showed that routine rounds were expected every two hours, primarily by CNAs and CMTs, to ensure residents were present and safe, and that intensive monitoring was understood by some staff to mean constant visual ability to see the resident. However, staff reported that when they believed they knew where residents were, they simply passed that information to the next shift without directly confirming the resident’s presence. The facility’s own investigation noted that a door alarm to the smoking area sounded between approximately 1:15 P.M. and 1:30 P.M., and a CNA obtained a key from the nurse’s station and turned the alarm off, with no documented verification that a resident had exited. The Administrator later stated that the alarm was not reported and that it was unknown whether anyone checked to see if a resident had gotten out. Medication administration records showed multiple scheduled medications, including psychotropic and other chronic medications, were not administered later that day and the following morning, with documentation indicating the resident was out of the building. The resident’s guardian reported that while out of the facility, the resident was not dressed appropriately for the weather, did not have a cell phone or wallet, and later told the guardian that the intent had been to get out for a while, and that the resident was “out of touch” and did not think clearly during this time.