F0689

J

Failure to Respond to Door Alarm Leads to Resident Elopement from Secured Unit

Giddings, Texas Survey Completed on 02-26-2026

Penalty

Fine: $19,120

Summary

The deficiency involves the facility’s failure to keep a resident’s environment as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents, resulting in an elopement from a secured unit. The resident was an elderly male with schizophrenia, Alzheimer’s disease, anxiety disorder, and recurrent major depressive disorder. His most recent MDS showed a BIMS score of 2, indicating severe cognitive impairment, with documented hallucinations, delusions, and wandering behavior occurring 1–3 days during the look‑back period. His care plan and elopement assessment identified him as an elopement risk and noted poor safety awareness related to his Alzheimer’s disease and schizophrenia, and he resided on a secure unit due to this risk.

On the night of the incident, the resident was on the secured unit lobby area in his wheelchair, with another resident on a couch nearby. LVN A, the charge nurse on duty for the 6:00 pm to 6:00 am shift, reported that at about 1:00 am she rounded on the secured unit and instructed CNA B, an agency CNA assigned to the secured unit, to sit close to the two residents in the lobby area to monitor them. Around 2:00 am, LVN A returned to the unit and noted that the resident was no longer sitting where she had last seen him. At approximately the same time, a police officer arrived at the facility and asked if they were missing a resident, describing a man in a yellow wheelchair matching the resident’s description.

Interviews and written statements showed that CNA B had heard the secured unit door alarm sound about 20–30 minutes before police contact but did not notify LVN A or check outside the door. CNA B reported that when the alarm sounded, she went to the door, saw the other resident sitting on the couch near the door, and assumed that resident had triggered the alarm. She turned the alarm off, did not look outside, did not conduct or request a head count, and did not inform the charge nurse that the alarm had gone off. As a result, the resident was able to leave the secured unit through the lobby door without timely detection. The resident was later found by local law enforcement walking along a major state highway approximately 0.9 miles from the facility in the early morning hours and was returned to the facility, where assessment documented no apparent injuries and stable vital signs.

The surveyors determined that this failure to respond appropriately to the door alarm and to follow elopement procedures constituted noncompliance at the level of Immediate Jeopardy (IJ) beginning on 02/23/2026 and ending on 02/25/2026. The noncompliance was identified as Past Noncompliance (PNC). The deficient practice was cited for failing to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for one of five residents reviewed for accidents and hazards.

Removal Plan

• PD brought Resident #1 back to the facility
• Resident #1 was assessed head to toe and had no apparent injuries
• Resident #1 was placed on 1:1 monitoring
• Resident #1 and all other residents in the facility were reassessed for elopement risk
• Staff were in-serviced on elopement
• Staff participated in elopement drills twice since Resident #1's incident
• Door stoppers were placed on 2 of the secure unit doors
• The staffing Agency was notified of agency staff actions
• Maintenance checked alarms and door magnetic locks
• The MD was notified of the incident
• An Ad hoc was held