F0689

J

Failure to Provide Adequate Supervision and Individualized Elopement Interventions

Robbinsdale, Minnesota Survey Completed on 03-17-2026

Penalty

Fine: $89,050

Summary

The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and individualized, care-planned interventions for residents at risk of elopement. One resident with severe cognitive impairment and a diagnosis of malnutrition was initially assessed on admission as non-wandering and completely dependent for mobility and personal care. However, an elopement assessment completed days later identified this resident as an elopement risk who was able to self-propel a wheelchair, was cognitively impaired, actively exit-seeking, and expressing a desire to go home. The resident’s care plan, initiated after this assessment, included use of a wander device, monitoring the device for proper functioning, and prompt response to door alarms, but it lacked specific supervision measures and individualized interventions tailored to the resident’s escalating exit-seeking behavior.

In the days leading up to the elopement, multiple progress notes documented that this resident was wandering up and down the hallway, confused, disoriented, and repeatedly attempting to leave the facility despite staff redirection. On the day of the elopement, documentation indicated the resident was very agitated, wandering into other residents’ rooms, calling the police, stating staff were holding her hostage, and attempting to leave multiple times. Video surveillance from the floor exit area showed the resident making several attempts over the course of the evening to open the stairwell and exit doors, triggering alarms that were reset by staff who redirected her away from the doors. Despite these repeated attempts and clear evidence of escalating exit-seeking, no additional formal interventions beyond the wander device were implemented, and staff did not revise the care plan to include increased supervision or other individualized strategies.

Later that evening, the video showed the resident successfully exiting through the floor door without staff present. A police report documented that the resident, who was not dressed for the weather and wearing all black, was later found about five blocks from the facility after knocking on a private residence’s door and asking for help. She was transported to the hospital for evaluation and was discharged in stable condition without injuries. Interviews with staff revealed that agency NAs working that shift were not informed which residents were at risk for elopement and that their care sheets did not identify elopement risks or related interventions. Additional residents assessed as elopement risks also had care plans that included wander devices and general directions to monitor for exit-seeking and answer door alarms, but these plans similarly lacked specific supervision measures and individualized interventions, and NA care sheets did not consistently reflect elopement risk status.

The facility’s elopement policy directed staff to establish a process to check bracelet alarm/device batteries according to manufacturer directions, and the user guide for the wander management transmitters required at least weekly testing to verify proper operation. Interviews with nursing and management staff showed inconsistent understanding of responsibilities for testing and ensuring functionality of wander devices, as well as for updating care plans and communicating elopement risk to direct care staff. Some nurses believed only nurse managers or the DON could change care plans, while the DON stated all nurses could make care plan changes. Nurse managers reported that residents at risk for elopement should be noted on NA care sheets, but agency NAs reported they were not alerted to any residents at risk to wander or elope. These documented gaps in assessment translation to care plans, supervision, communication, and device management contributed to the resident’s elopement and the identified deficiency.

Three additional residents identified as elopement risks had diagnoses including dementia, moderate to severe cognitive impairment, and conditions such as breast cancer and acute encephalopathy. Their elopement assessments indicated confusion, disorientation, and requests to go home. Their care plans directed use of wander devices, monitoring and documentation of exit-seeking behavior, prompt response to door alarms, and inviting them to activities, but similarly lacked explicit supervision requirements and individualized interventions to prevent elopement. NA care sheets for these residents either did not indicate elopement risk or did not include interventions to prevent elopement. These findings showed that the facility failed to consistently integrate elopement risk assessments into clear, individualized supervision strategies and to communicate those strategies to all staff responsible for resident care.