F0689

J

Failure to Prevent Elopement and Implement Required Safety Measures for Residents With Restricted Passes

Peoria, Illinois Survey Completed on 09-03-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent elopement for multiple residents with restricted community passes. One resident with a history of disorganized and paranoid schizophrenia, bipolar II disorder, delusional disorder, personality disorder, anxiety, poor insight and judgment, scattered thought process, poor decision-making skills, and poor safety awareness had been assessed as not capable of unsupervised outside community passes and did not know the facility address or how to contact someone in an emergency. Despite this, the resident’s care plan did not include safety interventions related to restricted community pass status and did not document the pass restriction. On the day of the incident, the resident independently called a taxi using a personal cell phone, walked out the front door, and entered the taxi while staff and security attempted to stop the departure, and the resident instructed the driver to leave. The resident was later returned by the taxi company, but there was no documented assessment after return, no initiation of elopement precautions, and no 15‑minute checks or other monitoring documented in the medical record.

Staff interviews revealed that the nurse who was aware of the elopement did not document the incident, stating that the DON said she would chart it and citing staffing shortages and workload. Security staff reported seeing the resident outside on a cell phone and then entering a taxi, yelling for the resident to stop because there was no pass, and then notifying facility staff after the taxi left. Another security staff member assigned to the front entrance that day, who usually worked in housekeeping, stated he did not know the resident, did not recall any residents leaving, and was unaware the resident had exited while he was on duty. Multiple CNAs and nurses reported they did not know which residents had passes or restricted passes, relied on a binder at the front desk that listed pass status, and stated they could not memorize all residents’ pass restrictions. Several staff members, including CNAs and an RN, stated they were not aware that the resident had eloped, that the information was not passed on to them, and that communication in the facility was poor, with management not informing them of such incidents.

Additional deficiencies were identified when two other residents with restricted community passes exited the facility unsupervised through a side door that had been propped open by an outside vendor working on the heating and cooling unit. One resident was observed outside near the main entrance and was escorted back into the facility, while another resident reported following the first resident outside to make sure he did not leave and then yelling for staff. Staff interviews confirmed that both of these residents had restricted passes and were not to leave without staff. The facility’s own elopement and missing person policy required that upon a resident’s return after elopement, staff initiate an assessment, notify family, complete documentation, place the resident on elopement precautions, review sign‑out procedures, and implement monitoring such as 15‑minute checks for at least 24 hours, with IDT reassessment. However, for the resident who left by taxi, these required steps were not implemented or documented, and the resident’s care plan and electronic medical record continued to lack updated safety interventions and monitoring strategies even days after the elopement. The cumulative failures in care planning, staff education on pass status, monitoring, communication, and adherence to the elopement policy resulted in an Immediate Jeopardy determination.