F0689

J

Elopement of Cognitively Impaired Resident During Unmonitored Exit Opportunity

Houston, Texas Survey Completed on 02-09-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one cognitively impaired resident. The resident was an older male with vascular dementia and a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment. His MDS indicated no documented wandering or behavioral issues and a need for partial/moderate assistance with transfers and ADLs. His comprehensive care plan, initiated several days before the incident, did not identify him as an elopement risk. A physician order allowed him to go out on pass with medications, and the DON stated that residents and responsible parties were educated on admission that residents were to sign out when leaving on a pass, but the DON also acknowledged that this resident was not compliant with signing in and out.

On the evening of the incident, the resident was last clearly observed by staff between approximately 5:00 p.m. and 7:00 p.m. CNA E reported assisting him to the dining room for breakfast and lunch and later seeing him seated in a chair in his room around 6:30–7:00 p.m. while providing care to his roommate. CMA A documented administering his evening medications at approximately 7:18 p.m. and then continued her medication pass and responded to other residents’ needs. At some point after this, CNA E returned to the room and found that the resident was no longer present, and she notified other staff. Nurse A, who was familiar with the resident but not his primary nurse, recalled seeing him sometime after dinner between 5:00 p.m. and 6:00 p.m. and stated that an elopement code was implemented around 8:00 p.m. after staff notified her that the resident was missing. The receptionist, whose shift that day ended at 5:00 p.m., stated that front door coverage was expected until 8:00 p.m. and that the front desk was not to be left unattended, but she was not present at the time the resident went missing.

The DON and other records indicated that the resident did not sign out and there was no entry for him on the facility’s entrance and exit log on the date of the incident. The DON stated that there was no policy specifying how frequently staff should round on residents and that residents had the right to leave during identified pass hours, while the facility remained responsible for their safety and accounting for their whereabouts. The DON also reported that staff were aware the resident was not compliant with sign-in/sign-out procedures. Around the time the resident was discovered missing, another resident-related emergency occurred that required a 911 call and the presence of first responders, during which the facility’s front door was held open as another resident was prepared for transport. Based on the facility’s root cause analysis, the DON stated it was likely that the missing resident exited the building during this emergency response. The resident was later found approximately seven miles from the facility in the parking lot of a local emergency care center with a laceration to his right eye and minor injuries to his hands, and he required hospitalization for evaluation and treatment.

Hospital records documented that the resident was brought to the emergency department by a local unhoused person who found him in the parking lot. On arrival, he was cold, bleeding from his right scalp, and had minor lacerations to both hands. A CT of the head showed right periorbital soft tissue swelling consistent with trauma from a fall, and he was found to be dehydrated, requiring hypotonic saline. The ED physician obtained history from the nursing facility and the resident’s family, noting that he had been placed in the facility due to difficulties with ambulation but was able to ambulate with a walker at admission. Facility documentation and interviews confirmed that staff did not witness his exit, that he was not accounted for through the sign-out process, and that he was ultimately reported missing to police later that evening, after which he was located offsite and transferred to the hospital.