Failure to Ensure Effective Post‑Elopement Window Safety Measures for an Exit‑Seeking Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and ensure the effectiveness of post‑elopement interventions for a resident assessed as an elopement risk. The resident was admitted with dementia with psychotic disturbance and anxiety, had a BIMS score of 4/15 indicating severe cognitive impairment, and was documented as ambulatory with a history of elopement attempts and wandering that placed him at significant risk of reaching dangerous areas. An FRI documented that the resident broke his room window and eloped from the memory care unit, after which one‑to‑one supervision was ordered until the window was amended. The resident’s elopement risk assessments and MDS continued to show a high elopement risk and wandering behaviors occurring on multiple days. Following the elopement, the care plan identified the resident as having a history of elopement out of the window and at risk for elopement related to dementia, with interventions including 1:1 care until the window was repaired. Progress notes over the subsequent months documented repeated statements by the resident about breaking and jumping out of the window, wanting to leave, and exit‑seeking behaviors such as wandering halls, going from door to door, pushing on exit doors, and packing belongings to leave. Staff notes indicated the resident was placed on 15‑minute checks at times due to wandering and exit seeking, and multiple entries described the resident expressing intent to break the window, jump out, or leave so that he might be harmed. Despite the resident’s ongoing exit‑seeking and window‑focused statements, the facility’s physical intervention on the window was not effectively monitored or verified. The maintenance director reported that after the elopement he installed screws on the resident’s window and other windows but did not document follow‑up, did not physically test the windows to see if they could be opened over the screws, and only visually confirmed the presence of screws. During surveyor observation, the resident’s family member and the surveyor were each able to unlock and open the resident’s window fully over the screw with little effort, and the window screen was observed to be busted at the bottom. Staff interviews confirmed that the resident and his daughter liked the door closed, and that the resident continued to talk about leaving and was exit seeking for a while after the elopement, while leadership acknowledged there was no documentation of window checks and that they believed the windows had been repaired.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.