GLASGOW, KY - A resident with documented cognitive impairment and high wandering risk walked out of Glasgow State Nursing Facility unsupervised in the early morning hours, traveling more than half a mile down the street before staff located him.
Federal inspectors from the Centers for Medicare & Medicaid Services determined the facility's supervision failures created immediate jeopardy to resident safety, the most serious category of nursing home violations. The inspection, completed July 10, 2024, followed a complaint investigation into the June 24 incident.
Care Plan Existed But Was Not Followed
The resident, identified as R1 in inspection documents, had been admitted to the facility in March 2023 with diagnoses including polysubstance abuse disorder, chronic schizophrenia, and neurocognitive disorder. A cognitive assessment from May 2024 showed the resident scored eight out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment.
Facility staff had conducted a formal wander risk assessment on April 22, 2024, which assigned the resident a score of 13—indicating high risk for wandering and requiring specific precautions. The comprehensive care plan, dating back to March 2023, clearly documented multiple interventions staff were required to implement.
These interventions included redirecting the resident away from doors and back to his room, ensuring all doors were securely closed when entering or exiting the unit, and observing for wandering behavior with redirection as needed. The care plan specified that if a resident had been identified as high or moderate wander risk, staff should pay close attention and implement increased monitoring using an Increased Monitoring Log when necessary.
An intervention added May 9, 2024, required the resident to be on close observation—meaning within staff's line of sight at all times—from 9:00 PM to 7:00 AM. The elopement occurred at 6:09 AM, during the period when close observation should have been in effect.
The Morning of June 24, 2024
On the morning in question, a dietary aide exited the resident's pod area without ensuring the door closed properly behind him. The staff member later acknowledged he had been in a hurry to return to the kitchen and had not secured the door as required. He did not see the resident follow him out and only became aware a resident was missing when someone paged it overhead.
The resident passed through the unsecured pod door and continued through the facility to the front entrance. A security guard was stationed at the front desk but did not recognize the resident. In an interview with inspectors on July 3, 2024, the security guard stated he saw someone wearing a gray shirt leave through the front door at 6:09 AM but assumed the person was a staff member. The security guard reported he had never had contact with any residents in the facility, though he had been trained on the elopement binders.
The resident walked independently down the sidewalk, traveling 0.6 miles from the facility before a staff member located him on the street at 6:20 AM—11 minutes after his departure was captured on security cameras.
Understanding Elopement Risks in Nursing Homes
Resident elopement represents one of the most serious safety risks in long-term care facilities. When residents with cognitive impairment leave a facility unsupervised, they face multiple dangers including traffic accidents, falls, exposure to extreme temperatures, dehydration, and becoming lost.
Residents with dementia or other cognitive disorders often lack the judgment to recognize dangerous situations. They may not remember their address, be unable to ask for help, or fail to recognize when they are in danger. Disorientation can worsen once outside familiar surroundings, even for residents who seem oriented within the facility.
The risk increases significantly for residents with psychiatric conditions combined with cognitive impairment, as unpredictable behavior patterns can emerge. Wandering behavior in residents with schizophrenia and neurocognitive disorders requires consistent monitoring because the resident may not respond predictably to environmental cues or redirection attempts.
Time is critical in elopement situations. Research indicates that approximately half of individuals with dementia who wander and are not found within 24 hours will experience serious injury or death. Even shorter periods without supervision can result in harm, particularly in areas with vehicular traffic or environmental hazards.
Multiple System Failures
The inspection identified several breakdown points in the facility's safety systems. The dietary aide admitted he should not have left the area until the doors were secured but failed to follow this basic protocol. This represented a direct violation of the resident's care plan, which specifically required staff to ensure all doors were closed securely when entering or exiting the pod.
The security guard's unfamiliarity with residents created another vulnerability. Despite being positioned at the front desk where he could monitor security cameras and observe people entering and exiting, he had no system for distinguishing residents from staff members. His training on elopement binders had not included any interaction with actual residents or photographs that would help him identify individuals who should not be leaving the building.
The nursing staff's implementation of the close observation requirement also failed. A nurse aide interviewed by inspectors stated the resident typically stayed in his room during the night but sometimes sat in a chair by his room door. However, close observation means maintaining the resident within line of sight at all times—not simply checking periodically or knowing general location patterns.
Another nurse aide told inspectors that prior to the elopement, the resident had been on close observation from 7:00 AM until 9:00 PM, but not during the overnight hours when the care plan specifically required it. This indicated confusion among staff about when the close observation requirement applied.
Industry Standards for Wandering Prevention
Federal regulations require nursing facilities to ensure residents cannot wander into dangerous areas or leave the facility unsupervised. Standard interventions for high wandering risk residents typically include environmental modifications, staffing strategies, and individual monitoring protocols.
Environmental controls may include door alarms, keypad access systems, camouflaged exits, and visual barriers that discourage residents from attempting to leave. However, these systems work only when staff respond appropriately to alarms and maintain awareness of resident locations.
Staffing strategies require adequate numbers of trained personnel who understand each resident's specific risks and care plan requirements. All staff members—not just nursing personnel—need training on wandering risks and procedures for maintaining building security. This includes dietary staff, housekeeping, maintenance workers, and security personnel who may encounter residents attempting to access exit doors.
Individual monitoring protocols must be specific, measurable, and consistently implemented. When a care plan requires close observation, every staff member on duty must understand what this means and who is responsible for maintaining visual contact with the resident during each shift.
Facility Response and Corrective Actions
The facility was notified of the immediate jeopardy determination on July 8, 2024. On July 10, 2024, the facility submitted an acceptable Immediate Jeopardy Removal Plan, alleging the immediate threat had been removed on June 25, 2024—the day after the elopement occurred.
State surveyors conducted an extended survey on July 10, 2024, to validate the facility's corrective actions. After reviewing the changes implemented, surveyors validated that the immediacy of the threat had been removed on June 25, 2024, as the facility alleged. The immediate jeopardy was therefore classified as "Past IJ," meaning the immediate threat no longer existed but the violation had occurred.
Surveyors determined the facility achieved substantial compliance—meeting federal requirements—on July 2, 2024, eight days after the incident.
The Director of Nursing told inspectors that policy revisions had been completed and all staff had been re-educated. She stated dietary staff had not previously been aware of what was on residents' care plans but all staff had now received training on ensuring pod doors were closed before leaving any area. She acknowledged that her expectations were for whoever was working the front desk to be observing the facility's security camera monitors.
The MDS Coordinator explained that residents' care plans were printed with annual or significant change assessments and kept in binders at each nurses' station, with updates made as changes occurred. She stated interventions had been in place for the resident and staff knew to make sure pod doors were closed before leaving the area.
The Facility Director stated her expectations were for staff to ensure resident safety and follow care plan interventions. She indicated that if residents were outside the pod area without staff, personnel were to stay with the resident, keep them in sight, and call for assistance.
Regulatory Classification and Oversight
The violation was cited under 42 CFR 483.25, Quality of Care, specifically F689, which requires nursing homes to ensure each area is free from accident hazards and provides adequate supervision to prevent accidents. The scope and severity was classified as "J"—immediate jeopardy affecting few residents.
This classification indicates inspectors determined the facility's failure to provide effective monitoring and supervision created a situation likely to cause serious injury, harm, impairment, or death to a resident. The designation of substandard quality of care triggers enhanced oversight and potential financial penalties.
Federal regulations hold facilities accountable for implementing the individualized care plans they create. Having a care plan that identifies risks and specifies interventions provides no protection to residents if staff do not consistently follow those interventions.
Lessons for Long-Term Care Safety
This incident highlights the critical importance of facility-wide awareness of resident safety needs. Wandering prevention cannot be solely a nursing responsibility when dietary staff, security personnel, and other departments have access to doors and common areas where residents may attempt to exit.
Effective elopement prevention requires multiple layers of protection: physical security measures, staff training across all departments, consistent implementation of individualized care plans, and systems for quickly detecting when a resident is missing. When any layer fails, residents with cognitive impairment face potentially life-threatening situations.
For families evaluating nursing home options or monitoring care for current residents, this case demonstrates the importance of asking specific questions about wandering prevention protocols, how facilities train non-nursing staff on resident safety, and what systems exist to detect and respond to elopement attempts.
The complete inspection report is available through Medicare's Nursing Home Compare website and the Kentucky Office of Inspector General for state-operated facilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glasgow State Nursing Facility from 2024-07-10 including all violations, facility responses, and corrective action plans.
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