F0689

D

Failure to Supervise High-Risk Resident Resulting in Elopement

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a resident environment free of accident hazards and to provide adequate supervision to prevent elopement for one resident identified as high risk. The resident had Alzheimer’s disease, severe cognitive impairment with inattention and disorganized thinking, delusions, and wandering behaviors occurring 1 to 3 days, as documented on an annual MDS. The resident used a wheelchair for locomotion, required supervision or assistance with most ADLs, was frequently or always incontinent, and had an order indicating they were incapable of making their own decisions. An elopement risk assessment showed a history of attempted elopement, wandering behavior, cognitive impairment, verbalizations about wanting to go home or leave the unit/building, and independent mobility, resulting in a high-risk elopement score of 19.

Despite this high-risk status, the facility did not consistently implement and document required monitoring interventions. Following an incident on which the resident was found off their unit in the kitchen by dietary staff, the resident was placed on 15‑minute visual checks and identified as an elopement risk with a medical alert and visual check orders spanning all shifts. However, review of visual check documentation revealed omissions on multiple days, including 8/12/2025, 8/13/2025, and 8/14/2025, and there was no documentation of visual checks during the time period when the resident later eloped from 3:00 p.m. to 3:30 p.m. on 8/27/2025. Staff on the resident’s unit were not aware when the resident was off the unit during the earlier kitchen incident, and the DON acknowledged the lack of documentation for ordered visual checks.

On 8/27/2025, video surveillance showed the resident exiting the building through a west wing fire exit door at 3:04 p.m., self‑propelling in their wheelchair onto the lawn and moving toward the employee parking lot, and then returning through the front entrance at 3:15 p.m. The Occupational Therapy Supervisor reported seeing the confused resident near the end of the employee parking lot and observing a social services staff member approach and assist the resident back toward the main entrance, after which therapy staff returned the resident to their unit and notified security. The DON and Administrator stated that the door alarm did sound when the resident exited, but staff may not have heard it because it was change of shift and staff were congregated near the nurse’s station. The DON also stated that an elopement risk assessment is completed on admission and after a resident wanders, and that the resident had been on visual checks since the earlier wandering incident, but could not recall whether the resident had a history of wandering beyond what was documented. Review of care plans showed no active care plan specifically addressing wandering behavior at the time, although a prior potential elopement care plan existed with interventions related to confusion/dementia and attempts to leave.