F0689

J

Failure to Prevent Multiple Elopements of Cognitively Impaired Residents

Williamsburg, Virginia Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for two residents assessed as elopement risks with moderate cognitive impairment. One resident (R14) had diagnoses including heart failure, acute respiratory failure, abnormality of gait, and a history of falls, and was care planned for wandering with interventions such as use of a wander guard/location monitor and redirection. An elopement assessment identified this resident as having wandering behavior occurring one to three days, at risk for getting to a dangerous place, with worsening behaviors and aimless wandering. Despite this, the resident’s quarterly MDS did not identify wandering behaviors, and the resident was able to remove the wander guard bracelet and leave the building without staff knowledge.

In the first elopement event for R14, a utility staff member observed the resident outside in the front parking lot next to his wheelchair, with a bruise and laceration under his right eye. The wander guard bracelet was later found in the resident’s laundry bin, and the resident reported that he had intentionally removed the bracelet because it was uncomfortable and waited until no one was looking so he could go outside. The receptionist, who normally monitored the main entrance, was on break and did not see the resident exit. LPN1 confirmed that the resident had rolled his wheelchair out the door to the front parking lot and that the resident had begun exhibiting increased wandering and exit-seeking behaviors.

In the second elopement event for R14, the admission coordinator noticed the resident sitting outside the facility in his wheelchair without staff supervision and redirected him back inside. Investigation showed that a CNA had taken the resident to the therapy gym and informed the PTA, then left after confirming the resident was still in therapy 15 minutes later. When therapy was completed, the PTA placed the resident back in his wheelchair and allowed him to return on his own, not being aware that the resident was a wanderer and not recalling a wander guard bracelet. The resident then turned toward the lobby instead of his unit and exited through the main entrance while the receptionist was again on a scheduled break.

The second resident (R59) had diagnoses including metabolic encephalopathy, schizophrenia, anxiety, delusional disorders, PTSD, and abnormality of gait and mobility, with a BIMS score indicating moderate cognitive impairment. The care plan identified potential for falls and wandering, with interventions including monitoring for wandering behavior, redirection, keeping side doors locked, monitoring placement of a wander guard bracelet, and offering 1:1 staff when indicated. A wandering/elopement risk assessment documented a history of wandering to find family or a pet, cognitive impairment, and a recent medication change to decrease behaviors, and led to the decision to add an elopement deterrent device and develop an elopement care plan.

For this resident, an earlier elopement incident involved leaving to the parking lot while fixated on finding her daughter, though staff kept her within constant sight and within about 10 feet. A later elopement involved the resident leaving the facility without staff knowledge and being found at a security gate approximately a mile from the entrance, sitting in the passenger seat of an independent living resident’s car. Staff statements indicated they did not see the resident leave and could not identify when she was last observed. It was suspected that she had followed a family or staff member out a side hall door closest to the guard house and main road. LPN2 reported that the resident wore a wander guard bracelet and frequently tried to remove it but did not know where the resident went or where she was found.

Additional observations showed that the wander guard alarm for R14’s wheelchair produced an audible alarm that could be hard to hear at the nurses’ station when there was a lot of noise, even though it also displayed on monitors. An elevator near the nurses’ station led to a basement hallway where a second wander bracelet alarm was present, but no staff were in that area during observation. This basement hallway led to an unlocked exit door to the outside and another unlocked door to a loading dock and ramp leading outside. The facility’s elopement policy defined elopement as a resident wandering away without staff knowledge, out of visual sight, and being incapable of finding their way back, and required immediate, coordinated response when a resident was reported missing. The events described showed that both residents were able to exit the facility or reach unsecured areas without staff awareness, despite identified elopement risk and existing policies and interventions.

This deficient practice resulted in the identification of Immediate Jeopardy and substandard quality of care at F689, with the Immediate Jeopardy beginning when R59 eloped from the facility and was later found at the security gate in another resident’s car.

Removal Plan

• Provide education to the Director of Nursing, Director of Social Services, the Minimum Data Set Coordinator for the risk of wandering.
• Record assessments in the resident's medical record.
• Identify residents at risk for wandering.
• Maintain wander guards for residents identified to need them.
• Check all external and lobby doors within the health and rehabilitation center to ensure that all doors are secured or have a wander guard system in place.
• Place a staff member to continuously supervise and monitor the lobby area outside of the health and rehab center lobby, elevator, and unsecured areas.
• Maintain supervision of this area until a wander guard is placed to ensure no access to an unsupervised area.
• Provide in-service education to all staff present on the wandering resident policy and wander guard protocol, including identification of residents at risk of wandering, the wander guard system, and the monitoring system of the lobby, secured areas, and the elevator.
• Provide in-service education to all incoming shifts of nurses, certified nursing assistants, and health and rehabilitation center staff on the wander guard system and identified target areas, including newly hired, unscheduled, and contracted staff prior to their next shift in the health and rehabilitation center.
• Assign the Administrator or Director of Nursing to be responsible for implementation of the removal plan.
• Conduct an impromptu Quality Assurance Performance Improvement committee meeting to review the facility's plan of correction and removal of immediate jeopardy, including the Medical Director.
• Inspect the wander guard system for proper function and inspect all exterior doors to ensure substantial compliance is maintained.
• Monitor and review this plan of correction through the Quality Assurance process to ensure ongoing substantial compliance is met, amending the plan of correction as needed.
• Implement the plan of correction.