F0689

J

Elopement of Cognitively Impaired Resident Through Window and Unlatched Secured Gate

Waco, Texas Survey Completed on 03-02-2026

Penalty

Fine: $19,120

Summary

The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision to prevent an elopement by a cognitively impaired resident. The resident was an adult male with diagnoses including unspecified dementia, unspecified mood disorder, and primary hypertension. His most recent Quarterly MDS showed a BIMS score of 3, indicating severe cognitive impairment. He was care planned for impaired cognitive function due to dementia and identified as an elopement risk, with interventions that included redirection and education on the protocol and hazards of leaving the facility. Despite this, he was placed on a secured unit for exit-seeking behaviors and remained at risk for unsafe wandering and elopement.

On the evening of the incident, the resident was at the nurse’s station yelling that he was an adult, could leave if he wanted, and requesting a beer. Staff attempted verbal redirection without success and contacted his POA by phone to help calm him. During the phone conversation, the resident became increasingly agitated, yelled at the POA, and then returned to his room while continuing to argue. Shortly thereafter, when the LVN went to reassess him, the resident was not in his room, bathroom, or closet. The window appeared closed, but the bottom of the screen had been pushed back, which the LVN did not initially recognize. The resident later reported that he had used a butter knife from lunch to remove bolts from his room window, climbed out, closed the window behind him, and then slid under the privacy fence to leave the premises.

The resident exited the secured unit through a back gate that was found ajar. Interviews with the DON, ADM, Maintenance Supervisor, and Maintenance Worker established that the secured gate’s latch mechanism did not lock properly and that the gate had last been used earlier in the day when a funeral home picked up a body. The Maintenance Worker stated he was expected to ensure the gate was latched properly and had visually checked it, but it was later determined that the latch did not fully engage. This malfunction allowed the resident, who had severe dementia and was on a secured unit for exit-seeking, to leave the facility grounds, walk to a nearby corner store in a high-crime area at a busy intersection, purchase a beer, and return independently approximately 20 minutes later. The facility’s policies on safety, supervision, wandering, and elopement existed, but the combination of the unsecured gate, the resident’s ability to manipulate the window hardware, and the failure to detect his departure in real time led directly to the elopement event.

Additional interviews further described the resident’s condition and behavior at the time of the incident. The resident stated he felt bored, felt like he was in prison, and believed he was in his hometown, where he was familiar with going to a local store for beer and tacos. He reported that he was not afraid of the neighborhood and did not realize he was not in his hometown. The Nurse Practitioner and Medical Doctor both confirmed that the resident had a BIMS score of 3, was on the secured unit for exit-seeking, and was not able to fully understand the consequences of leaving the facility unattended due to his dementia and inability to perform instrumental activities of daily living. The POA corroborated that the resident had dementia, often needed to be spoken to like a toddler, had difficulty remembering family members but could recall past activities, and believed he was in his hometown when he left through the side gate to go to the store. These factors, combined with the malfunctioning gate latch and the resident’s ability to defeat the window screen, resulted in the elopement and constituted the cited deficiency in accident prevention and supervision.