F0689

J

Failure to Supervise High-Risk Resident Resulting in Elopement and Delayed Emergency Response

Syracuse, New York Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for one cognitively intact resident with significant mental health and substance use history. The resident had diagnoses including cocaine and opioid dependence, other psychoactive substance abuse with mood disorder, suicidal ideations and past suicidal behavior, depression with psychotic features, PTSD, cluster B personality traits, chronic pain, COPD requiring 3L O2 via nasal cannula at all times, right eye blindness with depth perception issues, and poor safety awareness as reported by therapy and the physician. An elopement risk assessment completed on admission scored the resident as zero because they were documented as not independently mobile, and no elopement-related care plan interventions or wander alert device were implemented, despite the resident scoring above five on the Against Medical Advice (AMA) risk assessment and having suicidal ideations and substance use disorder. The basic care plan initiated for discharge did not include supervision or elopement prevention interventions related to the resident’s medical and behavioral history.

On the day of the elopement, the resident’s last documented meal was breakfast, and a nurse administered a scheduled medication at 2:00 PM. The resident later reported packing their bags, using a wheelchair with oxygen to reach the lobby, and then walking out the front entrance carrying their bags, leaving the oxygen behind because it was too heavy. The resident stated that no staff attempted to stop them, ask where they were going, or request that they sign out. A stranger in a car picked the resident up off the property, and the resident went to a friend’s house rather than their last known address. Facility documentation and staff interviews showed that the LPN assigned to the resident’s floor did not see the resident in the room at 2:45 PM, was told by the roommate that the resident visited friends on other floors, and continued to check back, finally initiating overhead pages and a Code White search around 5:45 PM when the resident still had not returned. Medication administration records for later that day were marked “Out of Building,” although there were no physician orders for the resident to be out on pass or to leave the building.

The facility’s Code White/Elopement policy required internal searches and announcements but did not specify a timeframe for calling 911 or define which outside agencies should be contacted. After the Code White failed to locate the resident, the facility delayed calling emergency services; 911 was not contacted until 11:16 PM, more than five hours after the Code White was initiated, during which time the facility did not know the resident’s whereabouts. Law enforcement records and interviews documented that staff told police the resident was free to leave, despite no documented discharge, no evidence of required AMA counseling, and no physician notification or discharge order. The AMA form was dated with the day of departure but was actually signed by the resident the following day at a friend’s home, with no documentation that the resident was counseled on risks or that the physician was notified. The facility’s own staff, including the NP and social work, reported they were not notified of the resident’s departure or elopement and that there was no clear documentation of when or with whom the resident left. Surveyors determined this failure to supervise and to promptly recognize and respond to the resident’s unaccounted absence constituted Immediate Jeopardy and substandard quality of care for the resident and others at risk of elopement or leaving AMA.

Removal Plan

• All residents in the facility had their elopement risk assessment completed in accordance with the Minimum Data Set and had interventions in place in accordance with the assessed risk.
• All residents assessed as an elopement risk that triggered the requirement for use of a Wanderguard bracelets had their bracelet in place.
• Residents with Wanderguard bracelets were placed on the Adventure Club list, which contains their picture indicating their elopement risk.
• The Adventure Club list was within the electronic medical records and available to staff.
• If the resident required 1:1 supervision, that supervision was provided.
• Exit doors were inspected, locked, and alarmed.
• Exit door functionality was confirmed.