F0689

K

Failure to Secure Windows and Exits for Elopement-Risk Residents

Aberdeen, South Dakota Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a resident at known risk for elopement, who left the building unsupervised through his bedroom window. The resident had dementia with severe cognitive impairment, anxiety, a documented history of wandering and elopement, and an elopement risk assessment score indicating he was at risk for eloping. He had a physician’s order for a WanderGuard and was identified as a wander risk. On the night of the incident, staff last observed him around midnight; at 4:10 a.m. a CNA entered his room and found him missing, with his window open and the screen pushed out. Staff searched the building and then the grounds, ultimately finding him lying in the grass outside at approximately 4:38 a.m., wearing layered clothing, with no major injuries and normal vital signs.

The facility’s own investigation determined that the resident’s bedroom window did not have a safety stopper in place at the time of the elopement, allowing it to be opened far enough for him to climb out. Although the care plan indicated that a window alarm had been placed on his window on the date of the incident, later observation by surveyors showed that there was no alarm on his window, only metal stoppers. The executive director stated that an alarm purchased after the incident did not fit the window and that another had not yet been ordered, and the maintenance director had not informed her of this. Staff interviews revealed that direct care staff were not aware that the resident was supposed to have a window alarm, and his Kardex and pocket care plan did not indicate a window alarm requirement, despite his exit-seeking and wandering behaviors, which included standing by exit doors with his coat and belongings and becoming more upset after family visits.

Beyond this resident’s room, surveyor observations on multiple dates showed that numerous other windows and doors throughout the facility were not adequately secured, despite the presence of other residents identified as being at risk for elopement. Several sliding windows in common areas such as the TV room, restorative room, therapy room, chapel, and multiple resident rooms could be opened far enough for a person to climb out and lacked metal stoppers. Some rooms near these unsecured windows housed residents at risk for elopement. Certain windows had stoppers on only one side, allowing the other side to open widely. In addition, several exit doors, including doors in the activity room, near the laundry room and employee break room, and two black doors in the dining room to the courtyard, were found unlocked and/or not alarmed or not properly checked, even though the administrator had attested that all exit door alarms were in working order. The maintenance director acknowledged he had not checked all exit doors since starting employment and had only been oriented to some of the exit doors. The DON reported being unaware of the resident’s exit-seeking behaviors, and CNA behavior documentation was not being completed because nurses were documenting, even though nursing notes largely did not reflect exit-seeking behaviors prior to the incident. These combined inactions and environmental hazards led to the determination of noncompliance at F689 with Immediate Jeopardy.

The facility’s policies required elopement risk assessments on admission and at set intervals, updating care plans based on risk, use of WanderGuards for moderate or high-risk residents, prompt response to exit alarms, and completion of missing resident drills on all shifts monthly. The resident’s record showed that elopement risk assessments had been completed and that he was identified as a wander risk with a WanderGuard order, but the environmental controls and care plan implementation did not prevent his unsupervised exit through the window. Staff interviews confirmed that residents had ongoing access to unsecured areas such as the television lounge, restorative therapy room, chapel, and therapy room, and that some of these areas contained windows that could be opened wide enough for egress. The combination of unsecured windows and doors, incomplete implementation of care plan interventions (including the missing window alarm), lack of full awareness of exit-seeking behaviors by key clinical staff, and incomplete maintenance checks on exit doors contributed directly to the resident’s elopement and the broader deficiency related to accident hazards and inadequate supervision.