F0689

D

Failure to Supervise Exit-Seeking Resident on 15-Minute Checks Resulting in Elopement via Unsecured Stairwell

New Britain, Connecticut Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and maintain an accident‑hazard‑free environment for a resident with known fall risk, cognitive impairment, and documented exit‑seeking behaviors. The resident’s diagnoses included generalized muscle weakness, lack of coordination, polyneuropathy, vascular dementia, history of TBI, alcohol and opioid dependence, anxiety, and depression. A fall risk evaluation identified the resident as a moderate fall risk, and the resident care plan documented a history of falls and risk for falls related to confusion, unawareness of safety needs, psychoactive and sedative/hypnotic medication use, impaired cognition, and poor impulse control. The care plan interventions included maintaining a safe environment, anticipating and meeting needs, monitoring for clinical and behavioral changes, and placing the resident on every 15‑minute monitoring for safety.

The clinical record and progress notes showed a pattern of increasing confusion, wandering, and exit‑seeking behavior over several weeks. Multiple nursing notes documented the resident going into other residents’ rooms, attempting to get to the elevator, searching for exit doors, and looking for family members. Psychiatric provider notes identified functional and cognitive decline, ongoing confusion, agitation, sundowning, wandering, and exit‑seeking, and confirmed that the resident was on every 15‑minute checks for exit‑seeking behavior. Despite these documented behaviors and the physician’s order dated 1/23/26 for every 15‑minute observations each shift, there was no evidence that additional environmental safeguards, such as a Wanderguard, were in place, and the resident was noted at one point not to be wearing such a device.

On the day of the elopement, the resident expressed a desire to leave and was told by a nurse that a leave of absence order was required. Later, camera footage showed the resident in the hallway looking around to ensure no one was present, then approaching a keypad‑secured stairwell door, entering the code observed from staff use, and exiting through the stairwell. The stairwell led down 4.5 flights of stairs to an unsecured exit door that opened directly to the street. The resident descended the stairs, exited the building, and walked approximately 0.5 miles along a main street without staff awareness. Staff did not realize the resident was missing until later, at which point a nurse documented that the last time she had seen the resident was at 1:00 PM. The resident was later located off premises and returned.

Documentation related to the ordered every 15‑minute safety checks was found to be inaccurate and not reflective of actual monitoring. The 15‑minute check sheet for the day of the incident showed continuous checks from 7:00 AM through 1:15 PM, including entries indicating the resident was in the hallway at times when camera footage and staff accounts established the resident had already left the unit and the building. Nursing assistants interviewed reported they had not actually performed the 15‑minute checks but were directed by the ADON, after the resident was discovered missing, to complete the check sheet despite the checks not having been done. One NA stated she estimated times and signed the sheet, including for intervals when the resident was off the unit. The DON and Medical Director later acknowledged that the psychiatric provider had not been notified promptly of the resident’s increasing confusion and exit‑seeking, that the 15‑minute checks were not completed as ordered, and that the medical record documentation was inaccurate and not completed at the time of observation, contributing to the failure to supervise the resident adequately and prevent the elopement.

Physical observation of the environment revealed that the stairwell door on the resident’s unit was secured only by a keypad and that the exit door at the bottom of the stairwell to the street was unsecured. The resident reported watching staff use the keypad until able to discern the code, then using it to open the door when staff were in other rooms. The DON confirmed that the keypad code remained unchanged after the incident and that staff were unsure how to change it. The facility’s fall prevention and documentation policies required individualized interventions based on fall risk and accurate, timely, factual documentation that reflects the resident’s actual experiences, and prohibited false information. However, there was no policy available for every 15‑minute checks, and the documented practice on the day of the incident did not align with the physician’s order or the facility’s documentation standards, resulting in the resident leaving the building and walking into the community without staff knowledge.