F0689

D

Failure to Adequately Supervise Resident Leading to Elopement

Jeannette, Pennsylvania Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one resident. Facility policy on Elopements and Wandering Residents requires a systemic approach to identifying and managing residents at risk for elopement, including assessment of risk, implementation of interventions, and vigilant staff response to alarms, with the understanding that alarms are not a substitute for necessary supervision. The resident involved was admitted in October 2024 and had diagnoses including cardiomegaly, hyperlipidemia, and anxiety. A BIMS score of 13 on the MDS indicated the resident was cognitively intact, and an elopement/wandering risk assessment completed in January 2025 documented that the resident was not at risk for elopement and not at safety risk for wandering, or wandered but was easily redirected.

On the date of the incident, a progress note documented that a nurse was informed by rehab staff that the resident was outside in a wheelchair. When the nurse went outside, the resident was found sitting in the wheelchair with a newspaper and wallet in hand, stating he was trying to go to an appointment, and had exited the building without staff knowledge. Facility documentation indicated that the receptionist saw the resident get his newspaper, then turned away to take a phone call and obtain a phone number, and when she turned back, the resident had left through the front door. The record also included a prior employee statement describing a different resident found outside in a power wheelchair in the back parking lot after having pushed sliding doors off their hinges to exit the building. During interview, the DON confirmed that the facility failed to provide adequate supervision resulting in an elopement for one resident.