C M Tucker Jr Nursing Care: Resident Elopement - SC
COLUMBIA, SC - Federal inspectors cited C M Tucker Jr Nursing Care Center for immediate jeopardy violations after a cognitively impaired resident escaped the facility on a day when temperatures reached 96°F.
Resident Escapes During Evening Hours
The July 6, 2024 incident involved a resident with documented wandering behaviors and moderate cognitive impairment who managed to leave the facility's secured area. Surveillance footage revealed the resident spent approximately 26 minutes outside the building before staff located him on the sidewalk, found on his knees past the main entrance.
The resident had been admitted with multiple conditions including wandering behaviors, coordination difficulties, walking problems, muscle weakness, and a history of falls. Despite these documented risk factors, facility staff failed to maintain adequate supervision.
Safety Systems Failed Multiple Times
Medical records show the resident had verbalized intent to leave the facility and was actively exhibiting exit-seeking behaviors. His elopement risk assessment, completed just days before the incident, specifically noted wandering behaviors occurring for 1-3 days and identified him as having a risk of accessing dangerous areas.
The facility had implemented a wander guard ankle monitor, but this safety measure proved insufficient when the resident discovered he could access exterior doors by holding them open for 15 seconds, as indicated by signage near the exits.
During the incident, the resident stated he "escaped this place" and explained that he "just went up to the door and held it for 15 seconds because that is what it says on the door." He reported he was looking for his truck in the parking lot.
Medical Risks of Unmonitored Exposure
Heat exposure poses significant medical risks for elderly nursing home residents, particularly those with cognitive impairments who may not recognize danger signs. At 96°F, the risk of heat exhaustion and heat stroke increases substantially, especially for individuals taking medications that affect temperature regulation or those with underlying health conditions.
Cognitively impaired residents face additional risks during elopement incidents, including disorientation, falls, dehydration, and inability to seek help. The combination of high temperatures and the resident's documented history of falls and muscle weakness created a potentially life-threatening situation.
Staff Response and Facility Procedures
According to nursing staff interviews, the resident was last seen watching television in the common area. During routine rounds, staff discovered he was missing from both the common area and his assigned room. The search process revealed gaps in monitoring procedures, as staff reported hearing alarm buzzing but initially did not investigate the source.
A certified nursing assistant found the resident outside after checking multiple areas including hallways, the café, and various doors throughout the facility. The staff member only realized the resident had exited when she heard the door alarm in a canteen room that provided access to the building's exterior.
Industry Standards for Elopement Prevention
Nursing home regulations require facilities to maintain comprehensive elopement prevention programs for at-risk residents. This includes regular risk assessments, appropriate supervision levels, environmental modifications, and staff training on monitoring procedures.
Effective elopement prevention typically involves layered security measures including door alarms, monitoring devices, staff observation protocols, and environmental design features that reduce exit-seeking behaviors. When residents have documented wandering behaviors and cognitive impairment, facilities must implement heightened supervision measures.
Facility Response and Corrective Actions
Following the incident, C M Tucker Jr Nursing Care developed a removal plan that included moving the resident to a secure unit with line-of-sight supervision. The facility conducted additional elopement risk assessments for all residents on open units and provided staff education on situational awareness and elopement procedures.
The facility's corrective measures included changing entrance codes every 90 days, evaluating door functionality, and incorporating the incident into monthly quality assurance meetings. Fire and life safety staff verified that all security doors were functioning properly following the incident.
The Centers for Medicare & Medicaid Services classified this violation as immediate jeopardy, indicating the facility's failures posed immediate risk to resident health and safety. This classification requires facilities to implement immediate corrective actions and ongoing monitoring to prevent similar incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for C M Tucker Jr Nursing Care from 2024-07-15 including all violations, facility responses, and corrective action plans.
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