Failure to Secure Main Entrance and Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the main entrance secured and to provide adequate supervision to prevent elopement for a resident with known elopement risk. The resident was admitted with encephalopathy, traumatic brain injury without loss of consciousness, unsteadiness of feet, and type 2 diabetes with kidney disease. An MDS dated 11/3/25 showed a BIMS score of 11/15, indicating moderate cognitive decline, and documented that the resident required supervision, verbal cues, and touching assistance for functional activities. An SBAR dated 10/31/25 documented that the resident had previously exited the facility unattended through an emergency door and was observed walking away from the facility, requiring three staff to follow and attempt to redirect him back. An elopement evaluation dated 10/31/25 indicated the resident had a history of elopement or attempts to leave without informing staff, expressed a desire to go home, and had goal-directed wandering likely to affect safety. Despite this, the care plan for risk of wandering/elopement initiated on 10/31/25 and reviewed on 12/2/25 did not include the use of a wander guard as an intervention. On 11/25/25, at approximately 6:30 a.m., staff discovered during routine rounding that the resident was not present on the unit, and there were no witnesses to the resident’s departure. Review of closed-circuit television confirmed the resident had eloped through the front main door. The facility’s investigative summary dated 11/27/25 documented that the resident had removed his wander guard and exited through the unlocked front door without supervision or authorization. The DON reported that kitchen staff had unlocked the front door to allow another kitchen staff member to enter and forgot to relock it as it was close to 7:00 a.m., leaving the front door unmanned while staff were busy with other resident care activities. A subsequent elopement evaluation dated 11/27/25 again documented the resident’s history of elopement, wandering, expressed desire to go home, and goal-directed wandering likely to affect safety, and a progress note dated 11/28/25 recorded ongoing noncompliance with wearing the assigned wander guard and a pattern of exit-seeking behaviors. Review of the facility’s policies on wandering/elopement and unusual occurrence reporting showed that staff were expected to follow or accompany residents who exit despite efforts to stop them and to conduct and document investigations including staff and witness interviews, but the DON acknowledged that written interviews from the staff who unlocked the main door were missing from the investigation summary and further attempts to interview that staff member were unsuccessful.
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