F0689

J

Elopement of At-Risk Resident Due to Door Alarm Failure and Inadequate Supervision

Camp Hill, Pennsylvania Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent the elopement of a resident identified as being at risk for elopement. Facility policy on elopement, revised June 2023, states that residents at risk for elopement will be appropriately monitored to reduce potential injury and defines elopement as a resident leaving the premises without staff knowledge and supervision. Resident 3 had an elopement care plan in place since November 2025, identifying a potential for elopement and associated injury related to exit-seeking behavior and a desire to go home. Interventions included reorientation, encouragement of group activities, provision of diversional activities when exit seeking, redirection from exits, and use of a wander guard device with checks for placement and function each shift.

Resident 3’s clinical record showed diagnoses including alcoholic cirrhosis of the liver, hepatic encephalopathy, and GERD. The resident had physician orders for a wander guard device, initially to the right ankle and later changed to the left ankle, with instructions to check placement every shift and function every night shift. An elopement/wander risk evaluation dated November 1, 2025, scored the resident as a moderate elopement risk. The care plan also documented that the resident required direct supervision while outdoors and needed one-person assistance with a walker for ambulation. Despite these identified risks and interventions, camera footage confirmed that Resident 3 exited the main entrance at 5:33 PM on February 4, 2026, without staff awareness.

The resident’s absence was not discovered until approximately 8:45 PM, when staff realized the resident could not be located on the unit and within the facility, and the resident had not signed out. Staff interviews and witness statements indicated that the resident was last seen around dinner time and that staff only began searching after a nurse aide noted the resident had been gone for a long time. The receptionist reported not noticing anyone by the door and not seeing the resident exit. The Nursing Home Administrator later stated that the facility determined there was an issue with the wander guard system at the main entrance door, which was alarming only intermittently and had a closing delay that could allow someone to exit without triggering an alarm. Resident 3 was ultimately found by a staff RN in the street approximately 0.3 miles from the facility, after having crossed a heavily trafficked roadway in cold, dark conditions. This failure to provide adequate supervision and maintain effective elopement prevention measures also placed eight additional residents with elopement risk and wander guard orders on unlocked units in an Immediate Jeopardy situation.

Removal Plan

• Resident 3 was returned to the facility with no adverse outcome, a new wander guard was placed on the resident, and an updated elopement evaluation was completed.
• All facility residents with active orders for wander guards had devices checked for function.
• House-wide resident elopement scores were reviewed for accuracy and to ensure care plans were in place as indicated.
• Elopement binders were reviewed and updated to include residents with wander guards.
• The door system was evaluated for function.
• The over-ride button at the receptionist desk was disengaged and disabled until the door and wander guard system is repaired and function validated.
• A service call was placed to the door company and repairs were scheduled.
• A surveillance camera was installed in the lobby to continuously monitor the lobby area.
• Signage was installed on lobby exiting doors to remind visitors and staff to check surroundings when exiting the facility.
• The building entrance door was monitored continuously by the receptionist or designee until repairs were completed and the door and system were fully operational.
• Facility staff were re-educated on the facility elopement policy.
• Reception staff were educated that the over-ride button was disabled and that manual code entry must be used to unlock the door.
• Facility staff were educated to be mindful of who is behind them when exiting and to monitor for residents attempting to exit before the door fully closes.
• The DON or designee will conduct observational audits of door code entry to ensure the door is monitored until fully closed and report results to QAPI.
• The Maintenance Director or designee will conduct door and wander guard function audits once the door is repaired and report results to QAPI.
• Wander guard function audits will be checked daily on the shift and report results to QAPI.