Elopement of High-Risk Resident Through Unsecured Back Gate
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevention of accidents for a cognitively impaired resident with known elopement risk, resulting in an elopement from the building. The resident was a 60-year-old male with diagnoses including cerebral infarction, COPD, asthma, hemiplegia, hemiparesis, aphasia, and depression. His quarterly MDS showed a BIMS score of 01, indicating severe cognitive impairment and that he was not interviewable. His care plan, dated 11/12/2025, identified him as having potential for behavioral problems and impulsiveness and specifically documented him as an elopement risk with a history of elopement from a previous nursing facility, with interventions such as assessing fall risk, redirecting, documenting wandering behaviors, and providing structured activities. On the day of the incident, the resident became agitated when a fill-in receptionist failed to obtain his usual coffee from a local coffee shop across the street, which staff had previously been bringing to him. During this time, the housekeeper took trash out to the dumpster through the back gate and failed to ensure that the gate locked behind her. The back patio area was described as a secure locked area with a long alleyway directly behind the facility. Because the gate did not lock, the resident was able to catch the door and roll his wheelchair out of the gate toward the alley in an attempt to get to the coffee shop located at the end of the alley. Staff became aware of the elopement when another resident reported that the resident had gone out of the back gate. The housekeeper reported that she then yelled the facility’s elopement code and ran outside, where a nurse was already present with the resident. An LVN and a CMA both reported that when they reached the resident in the alley, he had locked his wheelchair, was attempting to cross the alley, and became agitated and combative when they tried to redirect him back inside, striking the LVN in the face. The LVN stated she was only able to complete a range of motion assessment due to his aggression, while the ADON documented completing a head-to-toe assessment, change in condition assessment, smoking evaluation, and elopement risk assessment. The facility’s elopement policy stated that the facility would provide a safe environment as free of accidents as possible through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement, but the resident’s elopement occurred despite his known risk and care plan.
Removal Plan
- In-services for all staff on de-escalation, elopement, elopement binder location, and ensuring the gate closes completely and locks
- Documented door checks performed by the maintenance manager
- Elopement behavior quiz
- Positioned a staff member to sit at the back door
- Having a wander guard system installed
- Repaired/adjusted the gate lock so it clicks/locks once closed
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