F0689

J

Elopement Due to Unsecured Egress Door and Inadequate Supervision

Lockhart, Texas Survey Completed on 02-20-2026

Penalty

Fine: $22,320

Summary

The deficiency involves the facility’s failure to ensure the environment remained as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents, resulting in an elopement. The resident involved was an elderly female with vascular dementia, generalized anxiety disorder, major depressive disorder, insomnia, difficulty walking, unsteadiness on her feet, and a history of falling. Her quarterly MDS showed a BIMS score of 6, indicating severe cognitive impairment, and documented that she used a wheelchair and required substantial assistance to propel at least 150 feet. Prior to the incident, her care plan reflected impaired physical functioning and visual impairment, with interventions including independent wheelchair use and orientation to her environment, and there was no care-plan focus on elopement risk until after the event.

In the days leading up to the elopement, progress notes documented increased confusion and wandering-type behaviors. On one day, the resident was observed confused, out in the hallway and in another resident’s room, and was redirected back to her room. Bruising to her lower extremities was noted, with the resident unable to explain how it occurred. The DON discussed with the family member the possibility of moving the resident closer to the nurse’s station for closer supervision due to increased confusion, but the family member preferred that she remain in her current room at the end of the hall. Staff interviews later indicated that the resident had been noted to roam the halls, including being found on another hall and being redirected, and that she had attempted to go out the egress door near her room at approximately 3:00 AM a day or two before the elopement, with this behavior reported to a charge nurse.

On the day of the elopement, there was a thunderstorm and the facility’s power flickered or went out briefly, causing the delayed-egress magnetic locks on the doors to disengage and require resetting. Staff divided responsibility for checking and resetting doors, and 9 of 10 doors were reportedly reset and functioning properly; however, the egress door on the 200 hall near the dining room and the resident’s room was not reset or checked and remained unsecured. That evening, the resident was the last person in the dining room, taking a long time to finish her meal and milkshake. Staff who were aware she tended to wander left the area to assist on another hall and became busy, and the agency CNA who passed through the dining room later did not recognize the significance of the resident’s absence. The unsecured egress door between the dining room and the resident’s room allowed the resident to self-propel out of the building. She was later found outside on a side road behind the facility, next to an overturned wheelchair, and was brought back by a community member. Subsequent checks by the nurse revealed that the egress door near the resident’s room swung open and would not latch closed until maintenance staff manipulated the wall button and addressed the door closer, confirming that the door had remained disengaged at the time of the elopement.

Removal Plan

• Ensured all other residents were safe and accounted for.
• Ensured all doors functioned properly.
• Identified doors not functioning properly.
• Placed a CNA on doorwatch until the door was fixed.
• Assessed the resident with no adverse effects noted.
• Sent the resident to the hospital for further evaluation.
• Made notifications to the family, physician, DON, and administrator.
• Completed elopement risk assessments for all residents and updated care plans.
• Purchased a wander guard system for installation.
• Purchased and installed door alarms.
• Assessed outside surroundings near the door for hazards.