F0689

D

Failure to Prevent Elopement of Resident With Known Wandering Risk

Phoenix, Arizona Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The facility failed to provide adequate supervision to prevent an elopement for a resident with known cognitive impairment and wandering behaviors. The resident had multiple diagnoses including metabolic encephalopathy, dementia with agitation, cognitive communication deficit, gait and mobility abnormalities, and generalized muscle weakness. An admission MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and documented wandering behaviors occurring one to three times during the assessment period. The MDS also indicated the resident required supervision or touching assistance for transfers and ambulation and used both a walker and wheelchair. The care plan included a focus on dementia with interventions to monitor and report changes in cognition, and a separate focus on functional self-care and mobility limitations. Another care plan focus identified behavior problems including wandering and exit-seeking behaviors, resistance to care, and non-compliance, with interventions to anticipate needs and provide education.

Progress notes prior to the incident documented ongoing wandering behavior. A daily skilled evaluation note indicated the resident wandered in the hallway and appeared restless in his room, and another note documented wandering behaviors with instructions that staff were to anticipate his needs. A skilled needs review identified dementia, wandering, and elopement risk as barriers to discharge planning. Despite these documented behaviors and risks, the resident’s wander risk evaluation was not completed upon admission. The DON later acknowledged that the resident’s wandering assessment was not documented at the time of admission, even though the resident had been care planned for these issues.

On the day of the elopement, the resident’s blood sugar was checked and morning medications were administered around 7:00 a.m., and a progress note stated he was last seen at approximately 8:00 a.m. during the morning medication pass, when he told the LPN he was going to the dining room to wait for breakfast. Video surveillance from that morning showed the resident at the front entrance at 7:27 a.m., with no staff present in the lobby or at the door. The resident was seen attempting to push and pull on the locked exterior door until a security officer approached from outside. The security officer, who was unaware of the resident’s wandering history and did not recognize him as a resident, asked if he was visiting someone; the resident nodded yes and stated he was going to the second floor. The security officer then allowed him to exit and observed him outside for approximately two minutes before he left the property. The receptionist, who on other days controlled the front door and was aware of the resident’s wandering tendencies, was not on duty at the time. The resident subsequently left the premises, boarded a city bus, and was later located and returned to the facility by a family member, confirming that the resident had been away from the facility for an extended period without supervision.

The facility’s own five-day investigation determined that the security guard did not follow standards and protocol for verifying whether the individual leaving the facility was a visitor or a resident, and the elopement was substantiated. The facility’s policy on wandering and elopements stated that residents at risk of unsafe wandering would be identified and that staff observing a resident leaving the premises should attempt to prevent the resident from leaving in a courteous manner. In this incident, the resident’s known wandering and elopement risk, the lack of a completed wander risk assessment at admission, the absence of staff monitoring at the front entrance, and the failure of the security officer to correctly identify and stop the resident from exiting the building all contributed to the resident’s unsupervised departure from the facility.