F0689

J

Failure to Prevent Elopement of Cognitively Impaired Resident Resulting in Off-Site Fall

Tryon, North Carolina Survey Completed on 02-04-2026

Penalty

Fine: $24,850

Summary

The deficiency involves the facility’s failure to adequately supervise a cognitively impaired resident at known risk for elopement, resulting in the resident exiting the building without staff knowledge. The resident had dementia with moderate cognitive impairment (BIMS score 10/15), was resistive to nursing home placement, expressed a desire to leave or go home, and had poor decision-making skills. An elopement risk assessment identified the resident as at risk for elopement, and an elopement alarm bracelet was ordered verbally per the Medical Director and applied on 01/22/26, initially to the resident’s wrist and then additionally to her walker and cane when she repeatedly removed the device from her person. However, there was no corresponding physician order documented for the elopement alarm device in the physician orders at that time, and the alarm bracelet placement on equipment was contrary to manufacturer instructions, which specified that transmitters should be worn on the ankle or wrist and not directly attached to equipment.

On the morning of the elopement, multiple staff observed the resident wandering, confused, and exit-seeking over several hours. The Weekend RN Supervisor reported seeing the resident frequently between 7:30 AM and 9:30 AM, during which the resident was asking to leave, wanting to go outside, and attempting to open exit doors that remained locked and would not open for her. The Weekend RN Supervisor redirected the resident multiple times and had her sit in a chair near the 200 Hall medication cart, but after seeing the resident walk toward another hall around 9:30 AM, she did not see her again. A nurse aide assigned to the resident noted that the resident was walking around the hall and refused breakfast between approximately 8:30 AM and 9:00 AM, removed the breakfast tray, and then had no further contact with the resident that morning. Another nurse observed the resident at about 9:40 AM wandering on a different hall looking for turtles, walked her to a courtyard door to show where the turtles were, and then saw her walk back toward the nurses’ station near the front lobby; this was the last confirmed sighting of the resident inside the facility.

Despite the resident’s known elopement risk, active exit-seeking behavior that morning, and the presence of an elopement alarm system, no staff reported hearing an elopement alarm sound, and no one observed the resident leaving the building. The DON stated she last saw the resident standing by the nurses’ station approximately 15–20 minutes before being asked about her whereabouts by the Weekend RN Supervisor, and a facility-wide search (Code [NAME]) was not initiated until the resident’s family arrived for a visit and reported they could not find her. During the period when the resident’s whereabouts were unaccounted for, a civilian observed her walking along a public two-lane road without sidewalks in cold weather, and later found her down a steep embankment near a riverbed after seeing her walker abandoned by the roadside. EMS and fire personnel documented that the resident had fallen approximately 17 feet down the embankment, required rescue with a stokes basket and ladder, and was transported to the hospital, where she was found to have a right frontal forehead contusion but no acute intracranial injury. EMS personnel and the civilian both reported that no elopement alarm bracelet was observed on the resident at the scene, while the facility later confirmed that an alarm bracelet remained attached to the resident’s walker and that the device functioned when tested at the front door, indicating that the resident had been able to leave the facility without effective alarm activation or staff intervention.

Removal Plan

• Conduct staff interviews with nursing, dietary and housekeeping staff who were present and working during the time of the elopement.
• Initiate the missing person protocol and conduct a head count of all current residents, documenting that residents are present and accounted for.
• Contact the on-call physician and notify the Medical Director.
• Complete a full skin assessment upon the resident's return from the hospital and document findings.
• Check and test the wander management system and door alarms, including testing the bracelet through the front door, and have maintenance check alarm doors for faults.
• Determine the likely exit route and confirm other doors are locked and require a code.
• Reapply an alarm bracelet to the resident's person and maintain a wander alarm bracelet on the rollator walker.
• Update the resident's plan of care for elopement risk after readmission.
• Ensure the physician order for the wander alarm bracelet is entered into the electronic medical record.
• Update the elopement board and binders with the resident's picture and room number.
• Implement 1-on-1 supervision for the resident using licensed nurses, nursing assistants and dietary staff.
• Transition the resident to 15-minute checks as a trial with continued monitoring for further incidents.