F0689

J

Elopement of High-Risk Resident Due to Inadequate Supervision and Failed Wander Guard Protections

Memphis, Tennessee Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe environment and provide adequate supervision to prevent an elopement for a cognitively impaired resident with known wandering and exit-seeking behaviors. The resident had been admitted with multiple serious diagnoses, including traumatic subarachnoid hemorrhage, psychotic disorder, malnutrition, dysphasia, and a wedge compression fracture, and was assessed on the admission MDS as severely cognitively impaired with a BIMS score of 4. The admission assessment documented wandering behaviors on 1–3 days in the lookback period and a need for moderate assistance with ambulation. An elopement risk assessment completed on admission showed a score of 31, identifying the resident as at risk for elopement, with cognitive impairment, decreased safety awareness, judgment disturbances, a history/risk of wandering, and a history of one or two prior elopement events. Nursing documentation on 1/1/2026 described the resident as exit seeking several times after visitors left, stating he would leave when staff were not looking, and a physician’s order was obtained for a wander guard bracelet with every-shift checks for placement.

Despite these findings, the resident’s care plan dated 12/18/2025 did not address wandering or exit-seeking behaviors prior to the elopement. The care plan at that time only referenced a behavior problem with general interventions such as speaking calmly, diverting attention, and removing the resident from situations as needed. The DON later acknowledged in interview that the resident had not been care planned for wandering or exit seeking before the incident and that he should have been. The facility’s elopement and wandering policy stated that residents at risk for elopement would receive adequate supervision, that interventions would be added to the care plan and communicated to staff, and that door locks/alarms and wander guard systems were in place but not a replacement for necessary supervision. However, there was no evidence that the resident’s identified elopement risk and exit-seeking behaviors were incorporated into a person-centered care plan or that specific interventions for wandering were implemented before the event.

On the day of the incident, video footage showed the resident exiting the building through the front lobby without staff knowledge or assistance. The resident, wearing only a long-sleeved shirt, pants, and shoes, followed a visitor through the first set of doors, passed the receptionist, then followed the visitor through the second set of doors, walking past a housekeeper who was cleaning the lobby foyer. The resident then exited the front entrance and walked away from the facility along snow- and ice-covered walkways and roads in 21°F weather. The facility was not aware the resident had left until a family member called the receptionist to report that the resident was at a relative’s home, at which point a code white was initiated and a head count performed. Interviews and documentation indicated that the wander guard system at the front entrance did not alarm when the resident exited, and the Administrator later stated that the wander guard was not working properly at that time. The resident was ultimately found at a family member’s home after having fallen on an icy surface while exiting a private vehicle, and subsequent assessment and radiology confirmed an acute intertrochanteric fracture of the right hip. The facility’s failure to supervise the resident and to ensure that the elopement prevention systems and care planning were effectively implemented resulted in an Immediate Jeopardy citation at F689.

Removal Plan

• Completed a medical assessment for Resident #1 by the charge nurse and notified the Physician/Nurse Practitioner (NP) via the Assistant Director of Nursing.
• Administrator notified the physician and pain medications were administered as ordered by the charge nurse for Resident #1.
• Obtained an X-ray per physician orders for Resident #1; results showed an acute intertrochanteric right hip fracture; charge nurse notified Physician/NP and transferred Resident #1 to the hospital.
• Verified resident census and confirmed all residents present in the facility.
• Updated Elopement Risk Assessments for current residents to identify high elopement/wandering risk residents.
• Reviewed and revised care plans for all high elopement/wandering risk residents; updated interventions including wander guard placement for residents identified as high risk.
• Re-educated staff on the elopement/wandering policy, timely response to alarms, supervision expectations, and location of the Wander Guard Elopement Risk Binder; required completion prior to working.
• Revised maintenance procedures for auditing Wander Guard doors to include inspection of Wander Guard alarm panel integrity and hardware.
• Placed pictures and profiles for high-risk elopement residents with wander guard bracelets in the Elopement Risk Binder at the Reception Desk and at each nurses’ station.
• Provided 1:1 education to the housekeeper present at the door regarding recognizing wanderers/high elopement-risk residents and being observant in exit areas.
• Provided 1:1 education to the Maintenance department to check structural integrity of the wander guard door alarm system in addition to normal testing.
• Conducted elopement drills until all staff completed a drill and understood the process.
• Implemented Wander Guard alarm testing and door checks (including structural integrity) twice daily by Maintenance and/or Administrator; discussed results in QAPI and adjusted monitoring frequency based on audit results.
• Inspected the Wander Guard system; identified the front entrance panel as loose due to wear and tear; repaired immediately and tested the system as working correctly.
• Initiated enhanced monitoring at the reception area, including a Front Desk Visitor Screening Audit Log and Back Up Monitoring Log; educated Business Office Manager and Reception staff on these processes.
• Held an ad hoc QAPI meeting to review the incident, timeline, and immediate corrective actions with Medical Director participation.
• Implemented ongoing audits using the Wander Guard Door Alarm Audit and Front Desk Visitor Screening Audit Log.
• Completed vendor inspection and repair of the Wander Guard system by State Systems.