F0689

D

Failure to Supervise Cognitively Impaired Resident Who Left Facility Unnoticed

Richmond Heights, Ohio Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision to ensure that a resident with moderately impaired cognition did not leave the facility without staff awareness. The resident had multiple medical diagnoses, including non-traumatic intracerebral hemorrhage, hypertensive chronic kidney disease, end stage renal disease with dependence on dialysis, anxiety, and vascular dementia without behavioral, psychotic, or mood disturbance. A physician order directed that the resident wear a wanderguard bracelet on the ankle, with staff instructed to check its placement and function daily on day shift. The resident’s care plan identified him as an elopement risk who wandered aimlessly, with interventions to maintain the wanderguard, check its placement and function, provide diversionary activities, and redirect as appropriate. An MDS assessment documented moderately impaired cognition, independent ambulation, and instances of wandering, and noted that the resident had not utilized a wander or elopement alarm during the lookback period.

On the evening of the incident, the resident was last seen by staff in the late afternoon to early evening after telling staff he was going to the lobby to meet a friend. Later that evening, while passing medications, staff noted the resident was not in his room, and he remained absent through the night without staff knowing his whereabouts. The resident’s evening medications, including antihypertensive drugs and other treatments, were documented as not administered. Staff interviews indicated that a CNA who began the 7:00 P.M. shift noticed the resident was not in his room during initial rounds and again on a second check, but did not notify the nurse at that time, despite recognizing later that he should have done so. Another CNA reported seeing the resident fully dressed near the vending area stating he was going to the front to visit a friend, but there is no indication that this observation triggered any verification of his location or status afterward.

By early morning, nursing staff confirmed the resident was still missing, and a facility-wide search and missing resident response were initiated. The facility’s own elopement policy defined elopement as a resident leaving the premises or a safe area without authorization and/or necessary supervision, particularly when the facility is unaware of the resident’s departure or whereabouts. The resident later reported that he had left with a friend and spent the night at a family member’s home before returning. Upon return, assessments showed intact skin, no visible injuries, no pain or discomfort, and mental status at baseline, and he received breakfast and dialysis as scheduled. Despite the facility leadership characterizing the event as an unauthorized leave of absence, the survey findings focused on the lack of adequate supervision and failure to ensure that a cognitively impaired, independently ambulatory resident with a documented elopement risk and ordered wanderguard did not leave the facility without staff awareness.

The facility’s investigation timeline documented that all doors and windows, including the wanderguard system, were later checked and found to be in working order, suggesting that the resident’s departure occurred without triggering staff response through the existing monitoring systems. Staff accounts showed that the resident was known to walk around frequently but was not considered exit seeking by some CNAs, and one CNA reported that the resident had eloped a few weeks earlier. The combination of the resident’s known wandering behavior, his elopement-risk care plan, the presence of a wanderguard order, and staff failure to promptly report and act on his absence contributed to the deficiency in supervision that allowed him to leave the facility without staff knowledge.