BELLE FOURCHE, SD - Rolling Hills Healthcare faced regulatory scrutiny after a resident with dementia walked away from the facility undetected in the early morning hours, raising concerns about the accuracy of the facility's risk assessments and safety protocols.
Resident Leaves Facility Through Secured Courtyard
On June 24, 2024, at approximately 5:05 a.m., staff discovered a resident's walker near the courtyard door. Twenty-two minutes later, the resident was located walking in a field roughly two blocks from the facility. The resident had entered the security code to disable door alarms, exited through the enclosed patio and courtyard, and left the premises entirely.
The individual was returned to Rolling Hills Healthcare and assessed for injuries. While no physical harm occurred, the incident revealed significant gaps between the resident's documented risk level and actual behavior patterns.
Conflicting Assessment Results and Risk Determination
The resident's medical record contained contradictory information about cognitive function and safety risks. A May 28, 2024 SLUMS screening test—designed to detect mild cognitive impairment and dementia—produced a score of 14 out of 30, suggesting possible dementia. However, a March 20, 2024 Brief Interview of Mental Status showed a score of 15, indicating intact cognition.
Despite documented wandering behaviors and previous incidents, the facility's June 14, 2024 Elopement Risk Assessment classified the resident as low risk with no wandering behaviors. This determination occurred even though the care plan from June 12 specifically noted the resident "wandered outside, into other resident's rooms, hallways, and urinated outside."
When cognitive assessments produce conflicting results, healthcare facilities must reconcile the differences through additional evaluation and observation of actual behavior. Dementia can progress rapidly, and assessment tools measure different aspects of cognitive function. Relying on older data while ignoring current behavioral patterns creates dangerous safety gaps.
Pattern of Exit-Seeking Behavior Documented
Medical records revealed multiple instances of concerning behavior in the weeks before the elopement. On May 10, 2024, the resident had walked away during an outing with his spouse, requiring police intervention to return him to the facility. A certified nursing aide observed him walking along the street while his wife sat in their vehicle. When approached, he refused to return to the facility, stating "he intended to leave as soon as staff turned their back."
Progress notes from early June documented escalating concerns. A June 5 clinical note mentioned "some desire to exit building" and referenced a past elopement. By June 8, nursing staff reported the resident "will not remain in the facility" and was going outside to urinate, adding that he "refuses any and all behavior interventions suggested by staff."
Staff attempted multiple intervention strategies including distraction, redirection, games, one-on-one supervision, and family phone calls. Documentation indicated the resident "will not accept any interventions and is noncompliant with education given."
Exit-seeking behavior represents a critical safety concern in dementia care. When residents repeatedly attempt to leave, demonstrate knowledge of security systems, and verbalize intentions to exit, these actions signal high elopement risk regardless of formal assessment scores. The gap between documented behaviors and risk classification suggests the assessment process failed to incorporate observational data into safety planning.
Staff Recognized Risk Despite Official Assessment
Interviews with facility staff revealed awareness of the elopement danger that contradicted the formal low-risk classification. Multiple certified nursing aides reported the resident "often wandered" and had a history of going outside without informing staff. One aide noted his call light pendant—meant to help track his location—had been found in his trash can multiple times, indicating deliberate attempts to avoid monitoring.
A licensed practical nurse stated she believed the resident was at risk for elopement and that staff actively monitored him as he frequently approached courtyard doors. The director of rehabilitation described him as "exit seeking" before the incident, though noted he was "normally easy to re-orientate."
When direct care staff consistently observe behaviors indicating elopement risk, those observations must be incorporated into formal assessments and care planning. The disconnect between frontline staff awareness and documented risk levels suggests inadequate communication channels between observation and assessment processes.
Care Plan Modified After Incident
Following the June 24 elopement, the facility updated the resident's care plan to reflect elopement risk. New interventions included observing for knowledge of alarm codes, notifying the administrator if codes were known, providing constant supervision when the resident expressed intentions to leave, and offering supervised walks through the courtyard throughout the day.
These interventions represented appropriate responses to identified elopement risk—measures that should have been implemented when the pattern of exit-seeking behavior first emerged in May.
Additional Issues Identified
During interviews, facility leadership made conflicting statements about the resident's history. The administrator and director of nursing initially stated the May 10 incident was not considered an elopement because the resident's wife had "eyes on him at all times." However, the resident's spouse confirmed he had walked several blocks before police intervention was required—the first time such an incident had occurred.
The director of nursing also characterized a clinical note about past elopement as a "misstatement," claiming the resident had not left the facility before June 24. This assertion conflicted with documented evidence and staff interviews describing previous exit-seeking incidents.
The facility's March 2019 Wandering and Elopements policy required identification of residents at risk for unsafe wandering while maintaining the least restrictive environment. The March 2022 Resident Assessments policy emphasized that all care team members, including licensed and unlicensed staff, should participate in the assessment process—a requirement that appeared not to be followed when frontline observations of wandering behavior were not reflected in formal risk assessments.
State surveyors determined the facility failed to ensure accurate assessment of elopement risk, citing the provider for not meeting professional standards of quality in service delivery.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rolling Hills Healthcare from 2024-06-27 including all violations, facility responses, and corrective action plans.
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