F0689

E

Resident Elopes Outside After Door Alarm Not Fully Investigated

Maryland Heights, Missouri Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and oversight to prevent an elopement for one cognitively impaired resident who wandered outside unsupervised. The resident had severe cognitive impairment, diagnoses of Alzheimer’s disease, non-Alzheimer’s dementia, and insomnia, and was care planned as an elopement risk and wanderer. The care plan included every 15-minute checks due to attempts to get out of the building, monitoring when pacing to ensure the resident was not attempting to exit seek, a wander guard on the right ankle each shift, and 1:1 supervision from 7 p.m. to 7 a.m. due to attempts to exit the building. The resident’s medical record documented ongoing exit-seeking and wandering behaviors, including notes that the resident remained on frequent monitoring due to continued exit-seeking behaviors and that the wander guard was in place and functioning properly.

On the night of the incident, staff documented that the resident had been exit seeking and wandering, with interviews indicating the resident began exit seeking around 4:00 a.m. and was redirected from the exit door multiple times. CNA B reported that during the early morning hours, while providing care in a resident’s room, the door alarm sounded twice. The first time, around 5:30 a.m., CNA B found the resident and another known wanderer at the door, redirected both away from the exit, and returned them to the sitting area before resuming care of other residents. Approximately 15 minutes later, around 5:45 a.m., the door alarm sounded again. CNA B reported finding only the other wandering resident at the door, assumed that resident had triggered the alarm, turned off the alarm, and did not check outside the door or verify the whereabouts of the cognitively impaired resident.

Subsequently, CNA C in another housing unit observed the cognitively impaired resident outside, fully dressed, knocking on the door of that unit at approximately 6:00 a.m. CNA C recognized the resident as belonging to a different unit, escorted the resident back to the correct unit, and notified the CNAs there and the charge nurse. CNA E corroborated that the resident had been exit seeking earlier in the night and stated that the resident was calm and seated in the main area before staff began morning rounds. CNA E reported not hearing the alarm while in the shower room with another resident and only became aware the resident had been outside when CNA C returned the resident. The facility’s investigation concluded that the resident had wandered from the assigned building, walked through the courtyard to another building, and was outside unsupervised for an estimated five to ten minutes between the last sounding of the door alarm and being found at the other unit’s door. The investigation determined that although alarms functioned and sounded, staff did not check the outdoor area when the alarm activated the second time, and the DON and Administrator stated it was not appropriate for staff to ignore any alarm and that they expected staff to check outside and conduct a head count when an alarm sounded.

The resident’s medical record documented that when the incident was reported to the nurse, a head-to-toe assessment and neuro checks were performed, with no injuries or changes from the resident’s previous level of functioning noted. Due to poor memory, reasoning, and understanding, the resident was unable to provide an account of what had occurred. Progress notes around the time of the incident continued to describe the resident’s wandering, exit-seeking behaviors, and the use of frequent monitoring and observation precautions. Staff interviews and the facility’s written investigation emphasized that the resident had been wandering throughout the night and that, despite being on elopement precautions and having a wander guard in place, the resident was able to leave the unit and remain outside unsupervised until discovered by staff from another unit.