F0689

J

Failure to Supervise High-Risk Resident Resulting in Undetected Elopement

Waxahachie, Texas Survey Completed on 03-02-2026

Penalty

Fine: $19,120

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident identified as an elopement risk. The resident was a 92-year-old male with diagnoses including major depressive disorder, restlessness and agitation, impulsiveness, and dementia, and had been assessed on admission as high risk for elopement. His care plan, initiated several months prior, identified him as an elopement risk/wanderer with impaired safety awareness and included interventions such as distraction with pleasant diversions, structured activities, reorientation strategies, and use of a wander guard bracelet to alert staff if he attempted to exit the facility. Despite these identified risks and interventions, the resident was able to access and exit through a secured door without staff intervention.

On the day of the incident, facility video from a non-audio camera showed the resident standing alone in front of an exit door with his walker. The video reflected that he manipulated the keypad next to the exit door and pushed on the crash bar, which temporarily kept the door locked from the inside for 15 seconds. After this delay, he successfully opened the door and exited the building. The door closed behind him shortly thereafter. Approximately two minutes later, a facility staff member (FT) approached the same exit door, entered the alarm code on the keypad to turn off the alarm, and then walked away without opening the door or looking outside to determine whether a resident had exited.

Following his exit, the resident traveled down a concrete ramp, across a grassy yard, and crossed a residential street with a posted speed limit of 30 mph, ultimately falling on the ground in an adjacent parking lot approximately 500 feet from the exit door. The facility was not alerted to his absence by its own staff or alarm response, but instead was notified by a passerby who observed the resident on the ground and came to the facility’s laundry room door to report that a resident was across the street. Staff interviews confirmed that the facility’s expectation and training were that when a door or wander guard alarm sounded, staff were to open the door, look outside, and ensure no resident had exited before turning off the alarm. The Administrator, DON, ADON, HOH, CNAs, and nursing staff all stated that staff were trained not to simply silence alarms, but the FT who responded to the alarm did not follow this process, allowing the resident’s elopement to go undetected until reported by the public.

Interviews with multiple staff members, including the Administrator, DON, ADON, RN B, LVN A, HOH, and CNAs, consistently described that the resident had been identified as a wanderer and high elopement risk, and that staff were aware of the need to respond appropriately to door and wander guard alarms. The Administrator and DON both stated that all staff were expected to answer door alarms by going to the door, opening it, and looking outside for residents. The HOH and CNAs reported that housekeeping staff, including the FT, had been trained that if an alarm sounded, they were to look outside for a resident before turning the alarm off. Despite this, the FT’s response captured on video showed the alarm being silenced without checking outside, and the resident’s elopement was only discovered after he had left the premises, crossed a street, and fallen, demonstrating a failure to provide adequate supervision and to follow the facility’s elopement procedures for this high-risk resident.