F0689

J

Failure to Supervise Elopement-Risk Resident and Identify Prolonged Elopement

Edwardsville, Kansas Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards, resulting in an elopement. A resident with a diagnosis of schizoaffective disorder, hallucinations, delusions, rejection of care, and wandering behaviors was assessed as having intact cognition with a BIMS score of 15 and was care planned as being at moderate to high risk for elopement. The resident’s care plan included interventions such as increased supervision during exit-seeking behaviors, placement in a room away from exits, lodging in a secure unit, medication review, psychiatric services as needed, and use of a WanderGuard with placement and function checks. The WanderGuard was intended to limit the resident’s ability to enter the backyard without staff present.

Despite these identified risks and planned interventions, the resident was able to access the smoking patio and leave the facility without staff knowledge or supervision. At approximately 2:45 AM, the resident used a dining room chair placed on the smoking patio to climb over the tall fence surrounding the patio and exit the premises. The door to the patio remained unlocked, and although the WanderGuard alarmed at the door and indicated the need for staff assistance, the resident still gained access to the patio and then climbed the fence. The facility’s cameras later showed the resident using the chair to scale the fence. Staff statements indicated that the last known observations of the resident occurred between approximately 9:00 PM and 2:00 AM, with no indications of unrest reported at those times.

After leaving the facility, the resident walked approximately 1.8 miles to a truck stop, remained there for several hours, and then walked back to the facility, returning around 11:45 AM. During this time, outdoor temperatures ranged from 29.9°F to 45.3°F. Staff were unaware of the resident’s absence for about nine hours due to a failure to complete resident safety rounds on both the night and day shifts. Multiple staff members, including CNAs, a CMA, and an LN, reported not completing rounds or not entering the resident’s room, with one nurse noting that the resident’s curtain was pulled and she did not verify his presence. The resident ultimately rang the front doorbell to re-enter the facility, at which point staff assessed him and confirmed he had no injuries. The surveyors determined that the failure to complete rounds and adequately supervise the resident, combined with the environmental setup that allowed use of a movable chair to climb the fence, resulted in an elopement that constituted immediate jeopardy.