F0689

D

Unsupervised Resident Elopement Through Keypad-Controlled Exit

San Antonio, Texas Survey Completed on 03-20-2026

Penalty

No penalty information released

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 accidents, resulting in a resident leaving the facility without staff knowledge. The resident was an older female with multiple diagnoses including cerebral infarction, COPD, abnormal posture, muscle weakness, lack of coordination, dementia with agitation, heart failure, asthma, and a right wrist fracture. Her most recent MDS indicated adequate vision, cognitive intactness for daily decision-making, and independence with mobility, while her care plan documented impaired cognitive function, forgetfulness, and dementia with agitation. An elopement risk assessment documented that she ambulated independently, understood and accepted the need for nursing home care, had reasonable decision-making skills, no prior attempts to leave, recognized traffic controls, and knew her current residence.

On the evening of the incident, the resident received medications from an LVN at approximately 9:40 p.m. and expressed grievance about having a roommate after being promised a private room. The LVN reported calling the Administrator in the resident’s presence to relay the grievance, and the resident appeared satisfied at that time. Another resident in the same room stated that both received medications at around 8:30 p.m., that the aggrieved resident left the room around that time, and that she was not in the room when the roommate went to sleep at about 10:30 p.m. The roommate also reported that typically no one checked on her after the last medication pass and that she left her door slightly open if she needed staff attention.

Video footage showed the resident on the B Hall unit with two CNAs in the shower room between 11:00 p.m. and 11:15 p.m., then exiting the shower room around 11:30 p.m. with a CNA and walking with a walker back toward her room. At approximately 11:35 p.m., the resident was seen at the front door, using the keypad to activate the door code and exiting onto the sidewalk without staff intervention. The Administrator later stated that the resident had previously gone to a local fast-food restaurant but only when accompanied by staff, and that she somehow obtained or deduced the front door code despite not being given it. EMS contacted the facility close to midnight to verify whether the resident lived there, and the LVN subsequently found her at a nearby fast-food restaurant, where she appeared confused and denied recognizing him. The facility’s own policy on resident rights and safe environment stated that residents have the right to a safe environment and to receive care and services safely, but the resident was able to leave the building unsupervised by manipulating the keypad and walking approximately 0.1 miles away before staff became aware.