F0689

J

Elopement of High-Risk Resident Through Delayed Egress Door Without Adequate Alarm Response

Gasport, New York Survey Completed on 02-06-2026

Penalty

Fine: $12,740

Summary

The deficiency involves the facility’s failure to provide adequate supervision and assistance devices to prevent an elopement for one resident with severe cognitive impairment and known exit-seeking behaviors. The resident had dementia, chronic kidney disease, seizures, severe cognitive impairment, behavioral symptoms, rejection of care, and wandering behaviors documented on the MDS. The comprehensive care plan identified the resident as at risk for elopement related to confusion and dementia, with an intervention for use of a wander detection/monitoring device on the right ankle and a goal that the resident would remain on the premises. Additional documentation, including the Kardex and a Nursing Elopement Risk Data Collection Tool, showed the resident was independent with a rolling walker, had a history of unsafe wandering, opening outside doors, elopement, and making statements about leaving or seeking someone/something.

On the day of the incident, progress notes documented that the resident wandered throughout the shift, repeatedly called for help, expressed fear, and showed increased anxiety, with 1:1 support, food, drink, and toileting having no effect. The LPN supervisor reported that the resident had been following them around and was anxious, and that they last saw the resident between 9:15 PM and 9:30 PM, assuming staff had assisted the resident to bed. A CNA reported that around 9:00 PM they assisted the resident to bed after the resident asked for help. Despite the resident’s known elopement risk and active exit-seeking history, the resident was able to push on the delayed egress front door and exit the facility at 9:41 PM without staff knowledge.

Video surveillance showed the resident exiting through the delayed egress front door, and a CNA responding to the door alarm at 9:43 PM. The CNA stated they heard the alarm, went to the front entrance, looked into the entryway, did not see anyone, turned the alarm off, and reactivated the system without opening the exterior doors or checking outside, and did not notify the nursing supervisor of the alarm. The facility’s policies on elopement and security system alarms required staff to respond to alarms, ensure residents did not elope, and follow an organized plan to locate missing residents. However, no staff reported the alarm activation to the supervisor, and the LPN supervisor stated they were unaware the resident had exited until emergency services arrived and reported the resident was across the street in a parking lot. A police report documented that a caller found a confused elderly person at a nearby restaurant after a bystander had seen the person ambulating with a walker along a state highway and transported them to the restaurant parking lot, where emergency medical services identified the individual as having left the facility.

Removal Plan

• Assess resident for injuries.
• Update the resident care plan to include 1:1 staff supervision.
• Replace the delayed egress locking system on the front door with a wander guard locking system to keep the door secure unless a code is entered.
• Evaluate other exit doors and replace with a Mag Lock system.
• Ensure the resident has a wander alert device in place that works in conjunction with the wander guard locking system at the front door.
• Educate staff on elopement/resident safety and expectations when an alarm is activated.
• Conduct missing person drills.
• Conduct audits to monitor compliance with response to alarms and alerts.