Failure to Supervise Exit Door Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent elopement for a resident with known wandering and elopement risk. The resident was admitted with diagnoses including unsteadiness of feet, schizoaffective disorder, and an anxiety disorder, and was assessed on the MDS as having moderately impaired cognitive skills for daily decision-making. The resident’s care plan, initiated on 1/2/2026, identified risk for wandering/elopement based on prior attempts to leave the facility unattended and impaired safety awareness, including an incident on 1/2/2026 when the resident drifted away from a smoking group and was redirected back. The care plan interventions included door monitoring every shift and maintaining a safe, hazard-free environment. An Elopement Risk Evaluation dated 1/2/2026 documented a total score of 9 and noted that the resident had verbally expressed a desire to go home, packed belongings, or stayed near exit doors, and the summary of review stated the resident was at risk for elopement/wandering. On 3/14/2026, the resident was last observed at approximately 8:40 PM sitting in a wheelchair near the nurse’s station while a CNA supervised the front door. At approximately 9:00 PM, the charge nurse went to the resident’s room to administer scheduled nighttime medications and found the resident was not present. Immediate attempts were made to locate the resident within the unit and surrounding areas, but the resident was not found. Staff noted a bus in front of the facility and searched for it as part of the elopement search, but the resident was still not located. The Elopement Incident form indicated that the elopement occurred via the front door, and later documentation showed the resident stated she left through the front door and reported she was going to Oregon. Interviews with staff revealed that the front door did not have an alarm and was supposed to be supervised by staff and locked at night for safety reasons. CNAs and the LVN reported that staff routinely supervised the front door to prevent residents from leaving, and one CNA stated she supervised the front door from 8:00 PM to 8:30 PM on the night of the incident and did not see the resident near the front door or nurse’s station during that time. The LVN reported that when she returned to the nurse’s station after not finding the resident in the room, the resident’s wheelchair was present but the resident was not, and the front door was not supervised by the CNA who had previously been assigned there. The Social Services Director and DON both stated that the front door was to be supervised and monitored by staff to ensure residents’ safety and that it should not be left unattended, with the DON noting that the front door opens directly to a busy street and that the resident would not have been able to leave if the door had been supervised at the time of the incident. Facility policies on wandering/elopements and safety and supervision of residents stated that the facility would identify residents at risk, make the environment as free from accident hazards as possible, and ensure that supervision and interventions to reduce accident risks were implemented. Resident 1 was returned to the facility on 3/15/2026 at 1:15 PM.
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