F0689

J

Repeated Elopements and Self-Harm Due to Ineffective Supervision and Follow-Up

Broken Arrow, Oklahoma Survey Completed on 02-24-2026

Penalty

Fine: $30,470

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement and self-harm for a resident identified as high risk for wandering and elopement. The resident was cognitively intact on admission, with a BIMS score of 14, but had diagnoses including Huntington’s Disease, anxiety, depression, delusions, and hallucinations, and a history of falls prior to admission. The admission assessment documented that the resident wandered one to three days per week and that this wandering placed them at significant risk of getting to a potentially dangerous place. A care plan dated at admission identified the resident as at risk for elopement and wandering related to hallucinations, with interventions focused on distraction, identifying wandering patterns, monitoring for fatigue and weight loss, and providing structured activities and reorientation strategies.

A wandering risk evaluation completed shortly after admission scored the resident at high risk for wandering. Despite this, the resident repeatedly eloped from the facility. On one occasion in October, the resident left the facility without notice, crossed the parking lot, and fell in an adjacent field before being returned with assistance from local authorities; the facility’s intervention was to initiate visual checks every 15 minutes. In early November, staff documented escalating psychotic behavior, including the resident talking to themselves, insisting on contacting the FBI, and making threats toward staff and other residents. During this episode, the resident pulled a phone line from the wall and then ran out the front door, leading staff to call 911 and local authorities to locate the resident at a hotel. The facility later documented that the resident was involuntarily admitted to a hospital for psychiatric evaluation and treatment and subsequently returned to the facility.

Following the resident’s return, elopements continued. In mid-January, staff were unable to locate the resident in the facility; family located and returned the resident, and documentation showed the resident had intentionally burned the back of their hand with a cigarette lighter while away because they did not want to come back. The state reportable incident for that date documented the elopement and the use of every 15-minute checks but did not document the burn injury, which was later noted on a weekly skin observation as multiple blister sites from self-inflicted burns. In early February, the resident again left the facility after being denied early medication, walking out the front door after announcing they would leave; local authorities later found the resident at a residence identified as a known drug house. The resident eloped again the following day after being denied unscheduled medication and a supervised walk; staff did not realize the resident was missing for approximately 30 minutes, and family found the resident about a mile away at a local business. For each of these elopements, the facility’s intervention remained every 15-minute visual checks, and no new interventions were added to the care plan.

Staff interviews further described the resident as independent but needing supervision, with a history of illicit drug use and drug-seeking behaviors, and noted that behavioral triggers often involved not receiving medications when desired. An LPN reported that walking outside with the resident or engaging them in music sometimes helped, and that if the resident became too upset, they would call an ambulance or leave the facility. The DON acknowledged that the facility did not investigate the elopements to determine root causes, although camera footage was reviewed to see when and how the resident exited. The DON noted that on one occasion the resident watched activity around a back door before exiting, and that staff reports of when the resident was last seen were inaccurate compared to camera footage. The DON also stated that the intervention of every 15-minute checks did not appear to be effective, yet this intervention was repeatedly used as the primary response without modification of the care plan, contributing to the failure to provide adequate supervision to prevent further elopement and self-harm.

Removal Plan

• Place the identified resident on continuous 1:1 supervision (line-of-sight monitoring).
• Ensure the assigned 1:1 staff maintains visual contact with the resident at all times.
• Provide uninterrupted 1:1 coverage by relieving the sitter with a designated backup staff member during all breaks.
• Require the charge nurse to assign a backup sitter at the beginning of each shift.
• Document backup staff on the assignment sheet.
• Prohibit breaks without a confirmed face-to-face handoff between sitter and backup.
• Require the 1:1 staff to document every 15 minutes that they have eyes on the resident and the resident’s location on the 15-minute checks sheet.
• Require completed 15-minute check sheets to be turned in to the DON for approval.
• Assign a secondary staff member each shift as designated break coverage to ensure no lapse in supervision.
• Verify door alarm functionality immediately (maintenance and nursing staff).
• Update the resident’s care plan to reflect 1:1 supervision, high elopement risk status, and supervision requirements.
• Complete wandering risk assessments for all residents in the facility.
• Educate all staff on elopement risk, what to do in case of elopement (stay with resident, call 911, ensure safe return, notify charge nurse; charge nurse to notify physician/administrator/DON/family), and 1:1 sitter responsibilities.
• Do not allow staff who missed the education to clock in/work until education is provided and understood.
• Maintain attendance sheets in the education file.
• Review and update the resident’s comprehensive care plan via the interdisciplinary team to include high elopement risk identification, continuous 1:1 line-of-sight supervision, designated break relief protocol with face-to-face handoff, redirection techniques, monitoring frequency and documentation requirements, and conducting an investigation and root cause analysis after any additional exit-seeking behavior to update the care plan.