F0689

J

Failure to Supervise High‑Risk Wanderer Leads to Unnoticed Nighttime Elopement

Wilmington, North Carolina Survey Completed on 03-02-2026

Penalty

Fine: $23,230

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment for a resident with severe cognitive impairment and known exit‑seeking behavior, resulting in an unsupervised elopement at night in freezing temperatures. The resident had dementia with agitation, severe cognitive impairment on MDS, and documented wandering 4–6 days per week. Her care plan and physician orders required use of an electronic wandering alarm device, daily function checks of the device, and every‑shift checks of placement and battery, along with frequent safety checks due to high fall and elopement risk. The resident had a prior unsupervised exit from the facility, during which she fell outside the front entrance and sustained a head laceration, and she was identified by the facility as high risk for elopement and placed on 15‑minute observational checks.

Despite these identified risks and interventions, the facility’s alarm device system for the 200‑hall exit door had not been functioning properly since early January, and the annunciator for that door produced no audible alarm when a resident with an electronic device approached or exited. The Administrator, DON, and Maintenance Director all acknowledged awareness that the 200‑hall door alarm was not working, that the annunciator had been tampered with to reduce loudness, and that repair would not occur for several weeks. Although other exit doors and their alarms were reported as functional, the 200‑hall door—leading to a back parking lot, wooded area, ditch, and nearby road—remained in use and would open after being pushed for 15 seconds without generating an audible alarm in the building. Security camera coverage of this door was also partially obstructed by a tree and dumpster area, preventing direct visual confirmation of exits through that door.

On the evening of the incident, the resident was last clearly observed around 10:45 p.m. when a nurse retrieved her from another hall and returned her to the 200 hall, positioning her near the nurses’ station. The nurse responsible for the resident’s 15‑minute checks then focused on end‑of‑shift computer documentation and did not perform the required checks. At the 11:00 p.m. shift change, there was no clear handoff of responsibility for the 15‑minute monitoring between the off‑going nurse and the oncoming medication aide and NA; staff reported ambiguity about who was responsible for the checks at that time. The NA assigned to the resident began her shift by stocking supplies and answering call lights, assuming the nurse was performing the 15‑minute checks, and did not verify the resident’s whereabouts. Staff on the unit were unaware that the resident had left the building until two unknown individuals, who had found her outside sitting in a ditch, returned her in her wheelchair to a rear door shortly before midnight, at which time she complained of being cold. No staff member could account for the resident’s location between approximately 10:45 p.m. and her return, and the facility later determined by process of elimination and limited camera footage that she had exited through the non‑alarming 200‑hall fire door while wearing her electronic monitoring device.