F0689

J

Unsupervised Elopement Through Non‑Alarming Side Door and Inadequate Staff Awareness

Marion, North Carolina Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and to provide adequate supervision to prevent an unsupervised exit by a cognitively impaired resident. The resident had dementia, hemiplegia/hemiparesis following a cerebral infarction, anxiety, and depression, used a wheelchair, and required assistance with several ADLs. Staff, including multiple nurses and a nurse aide, reported that over several months prior to the incident the resident had experienced a decline with increased confusion, anxiety, disorientation in the hallways, difficulty finding her room, and forgetting that she required supervision to smoke. The resident’s care plan identified needs such as supervised leave of absence, variable mental function, risk for impaired vision, and risk for falls related to decreased mobility and muscle weakness, but there were no documented interventions for these care-planned problem areas.

On the day of the incident, the resident was observed by staff and witnesses in her usual routine near the nurse’s station and front area, then left unsupervised and exited the building without staff knowledge. The DON and Administrator later determined that the resident exited through a side door that, at that time, did not have an alarm that sounded when opened and only had a wander management alarm that would activate if a wanderguard bracelet was present; the resident did not yet have such a device. This side door and the front door were the only exterior doors that did not alarm when opened, and the side door was the only door that could not be easily visualized by the receptionist. Staff in the morning meeting were unaware the resident had left until a visitor (Witness #2) entered the conference room and reported that a resident was in the road.

Witnesses and staff described that the resident traveled down the ramp and out of the parking lot into a well-traveled two-lane road with blind curves and a posted speed limit of 35 mph. She was found in her wheelchair on the opposite side of the road from the facility, in the roadway, just past the gravel parking lot, attempting to self-propel further up the road. A passerby was present with the resident when staff arrived. The DON, ADON, Administrator, and other staff confirmed that the resident had actually left the building and was in the road, although the DON’s progress note and subsequent communication to several staff and the psychiatric provider characterized the event as an “attempted elopement” that had been intercepted by staff. Multiple staff members, including the assigned NA, several nurses, and the psychiatric provider, reported that they were only told it was an attempted elopement and did not know through the survey date that the resident had exited the building and gone down the road. The resident herself later stated she left the building in her wheelchair, went down the hill and up the road because she felt she needed to go home to care for her adult son, and she did not inform anyone she was leaving.

The facility’s leadership, including the DON and Administrator, acknowledged awareness of the resident’s recent cognitive decline and that she had been changed from independent to supervised smoking due to increased confusion and difficulty holding a cigarette. They also acknowledged that prior to the incident the side door did not alarm when opened unless a wanderguard was present, and that the front door and side door were the only non-alarming exterior doors. The DON stated that he believed he had verbally informed all staff that the resident had actually left the facility and gone down the road, but he did not track who he told, and several staff and providers confirmed they were not informed of the full extent of the elopement. The Administrator stated she was not sure why all staff did not know that the resident had actually gotten out of the building and would need to speak with the DON about his progress note describing the event as an attempted elopement. The surveyors concluded that the facility failed to provide necessary supervision to prevent the resident from exiting unsupervised through a non-alarming side door and failed to ensure all staff were aware of the unsupervised exit.

The report notes that the resident was not injured but that there was a high likelihood of serious harm, injury, or death, including risks of getting lost, falling without the ability to get out of harm’s way, or being hit by a car. The facility’s noncompliance was cited at Immediate Jeopardy level beginning on the date of the elopement, based on the unsupervised exit, the lack of an alarm on the side door, and the failure to ensure staff were aware of the actual elopement. Immediate Jeopardy was later removed after the facility implemented a credible allegation of immediate jeopardy removal, but the facility remained out of compliance at a lower scope and severity to ensure staff and providers were aware of the elopement and that education and monitoring systems were effective.