F0689

J

Failure to Supervise High-Risk Resident Resulting in Elopement

Dallas, Texas Survey Completed on 03-17-2026

Penalty

Fine: $19,120

Summary

The deficiency involves the facility’s failure to provide adequate supervision and assistive devices to prevent accidents, resulting in a resident’s elopement from the building without staff knowledge. The resident was an elderly male with dementia, prior cerebral infarction, hemiplegia/hemiparesis, generalized muscle weakness, and atherosclerotic heart disease. His admission MDS showed a BIMS score of 1, indicating severe cognitive impairment. An Elopement Risk Assessment completed shortly after admission scored him at 16, identifying him as at high risk for elopement, but his care plan dated 03/02/26 did not include elopement risk as a focus with goals or interventions. Progress notes from admission through the date of the incident documented no prior elopement attempts or exit-seeking behaviors.

On the night of the incident, the east exit door alarm sounded at approximately 01:00 a.m. The nurse on duty, RN A, reported that she immediately went to the door and looked but did not see any residents; she then conducted a head count and discovered that the resident was missing. The DON stated that RN A did not go outside the building to look for the resident when the door alarm sounded, and the administrator stated it was the nurse’s responsibility to go around the building at the time of the alarm. While the alarm had sounded and staff were searching, a CNA who worked on another floor encountered the resident outside around 12:30 a.m.; the CNA later stated in writing that he thought the man was homeless and did not recognize him as a resident because he worked on a different floor and had never seen him before.

After the resident was identified as missing, staff initiated the facility’s elopement/missing resident protocol and searched the building and surrounding premises, and local law enforcement was notified. Within a short time, police contacted the facility to report that the resident had been found wandering off facility grounds and transported him to a hospital for evaluation. The administrator reported that the resident was found near a hospital or a crossing bridge near the hospital, at least as far as the main road and not near the facility, estimating the distance as a 5–10 minute walk or longer for this resident. Hospital evaluation and subsequent skin assessment on return documented no injuries or acute issues. The DON later acknowledged that the resident’s high elopement risk score had been known, that the care plan should have reflected monitoring for elopement/exit-seeking behaviors, and that staff had not notified her when the resident’s initial elopement assessment score exceeded the facility’s high-risk threshold.