F0689

J

Failure to Supervise Exit-Seeking Resident Resulting in Unwitnessed Elopement

Dallas, Texas Survey Completed on 02-06-2026

Penalty

Fine: $12,740

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for one resident with known exit‑seeking behavior and prior elopement attempts. The resident was an older male with a history of cerebral infarction, osteoarthritis, schizophrenia, depression, anxiety, and documented dementia/non‑Alzheimer’s dementia in various records. His admission MDS showed a BIMS score of 13 with active diagnoses including non‑Alzheimer’s dementia and stroke, and he had been referred to psychiatry/therapy for depression, confusion, elopement, adjustment disorder, and high‑risk behavior. Progress notes and family interviews documented that he frequently talked about leaving, had a history of leaving prior facilities and psychiatric hospitals independently, and had previously left this facility and checked himself into a local hospital.

Elopement risk assessments and care planning for this resident were inconsistent and incomplete despite multiple documented episodes of exit‑seeking and actual elopement. An elopement risk evaluation on 10/13 identified him as a moderate risk, cognitively impaired and ambulatory, but later evaluations on 11/02 and 11/27 were documented as “No Risk” and only the “No Risk” sections were completed, even though the system had triggered questions for moderate or imminent risk that were not answered. There were discrepancies in the assessments regarding his ability to make decisions and ambulate. The care plan initially identified him as at risk for elopement and with impaired cognitive function/dementia, and noted psychotropic medication (Donepezil) for dementia, but the revised care plan dated 11/27 did not incorporate his documented elopement attempt and actual elopements on 10/24, 11/02, and 11/27. Progress notes described episodes where he went to the facility gate wanting to go home, required redirection, had two episodes of elopement with aggression and combativeness, and was sent to a psychiatric hospital with police involvement, as well as an episode where he independently checked himself into a local hospital after leaving the facility.

Despite this pattern, the facility’s clinical characterization of the resident’s cognition and risk status was altered without clear supporting documentation of a change in condition, and key information was not consistently communicated to the physician. On 11/27, the resident’s dementia diagnosis was struck out by the RNC after she determined he had a high BIMS score and was not exhibiting signs of dementia based on nursing assessments; she reported that the MD approved discontinuation of the dementia diagnosis based on the BIMS score. The MD later stated he was not aware of the resident’s exit‑seeking behaviors or elopements and that there was no documentation of these behaviors in his or the NP’s notes, although he saw that the resident was on dementia medication and did not know if the resident was safe to leave or ambulate independently. Staff interviews showed inconsistent awareness and recall of the resident’s elopements: some staff remembered retrieving him from the security gate, one nurse reported he was “very tricky” and had been on 1:1 observation and was not safe to be out alone, while others minimized or did not recall elopement events. Family members reported that the resident had dementia, wore a medical bracelet listing dementia and stroke, had left the facility multiple times through the fence or gate, sometimes calling them before the facility did, and that by the third time he left it was “scary.” Ultimately, on the cited elopement date, staff did not know what time he left the building; he climbed through the fence, walked several blocks away, contacted 911 himself, and was transported to a nearby hospital, where he was later located by the social worker calling local hospitals. These actions, inactions, and documentation failures led surveyors to identify a deficiency for failure to ensure adequate supervision and prevention of elopement, with Immediate Jeopardy cited on 02/05/2026.