F0689

J

Failure to Supervise Exit-Seeking Resident After Door Lock Failure Resulting in Elopement

Kansas City, Missouri Survey Completed on 03-05-2026

Penalty

Fine: $14,020

Summary

The deficiency involves the facility’s failure to ensure a known elopement-risk resident received adequate supervision and protection from accident hazards when the secured unit’s magnetic door locks and alarms were not functioning. The resident had multiple mental health and cognitive diagnoses, including schizoaffective disorder bipolar type, bipolar disorder, vascular dementia, anxiety disorder, impulse disorder, severe memory impairment, and was only oriented to self. A quarterly MDS indicated the resident had a history of wandering throughout the unit, entering other residents’ rooms, and exit-seeking behaviors. The resident’s care plan identified risk for wandering and elopement and directed staff to engage the resident in purposeful activity, identify times when wandering/elopement was more prevalent, and schedule regular walks.

On the day of the incident, a repeat BIMS documented that the resident was not cognitively intact. Later that day, nursing notes showed the resident verbally expressed a desire to leave the facility, continued to pack belongings, pressed emergency exit doors, and wandered into other residents’ rooms. Staff initiated frequent visual checks in response to these behaviors. Around 6:00 P.M., the magnetic locks on the main floor dementia unit lost power, and the resident exited the unit via a stairwell and reached the sidewalk before being quickly returned to the unit by staff. The Administrator was notified of the malfunction and arrived on-site, attempted to restore the locks, and contacted the repair company. The Administrator instructed the LPN to ensure the resident remained within line of sight at all times until the magnetic locks were repaired, and the LPN and CMT monitored the doors and the resident from the unit dining room.

Despite these instructions and the known door-lock failure, the resident was left unsupervised. After the first elopement, staff, including the LPN, CMT, and CNA, reported they tried to keep the resident in constant view and checked on the resident every few minutes. However, the CMT left shortly after the end of the shift, and the CNA was occupied preparing for the next smoke break. The LPN, who had been assigned to maintain visual oversight of the resident and the unsecured doors, went to the restroom for approximately two minutes without arranging coverage, even though the Administrator remained in the building and the CNA was present on another hall. When the LPN returned, the resident was no longer in the dining room, and a search revealed the resident had eloped a second time. The resident remained unaccounted for until the following afternoon, when the resident was found on a public transit system in a major metropolitan area and later evaluated at a hospital with no injuries identified. The facility’s internal investigation concluded there was a failure in the magnetic door locking system and in adherence to established policies and procedures, and that the facility was aware of ongoing door lock issues and the resident’s exit-seeking behaviors but failed to provide appropriate protective oversight, which directly contributed to the resident’s elopement.

The Administrator later stated that nursing staff had documentation from the previous facility indicating the resident was an elopement risk since the morning of admission, several hours before the resident arrived. The Administrator indicated there were only 15 residents on the unit with an LPN, CMT, and CNA assigned, and expressed that the LPN should have had time to review the admission information and communicate with the sending facility. The Nurse Practitioner reported an expectation that staff would have been aware of the resident’s exit-seeking behaviors and would have provided intensive monitoring after the first elopement, particularly given the resident’s need for a locked environment and the failure of the magnetic locks. The Administrator also stated that the event was preventable because the resident had two elopements within an hour, staff knew the magnetic locks were not working properly, and the LPN had been specifically instructed to keep the resident in line of sight until the locks were verified as working.