JONESBOROUGH, TN - Federal inspectors documented significant safety violations at Four Oaks Health Care Center after a cognitively impaired resident broke through a window lock and escaped the facility in October 2024, prompting a comprehensive review of the facility's security protocols and supervision practices.
Resident with Brain Injury Escapes Through Bedroom Window
The incident occurred on October 6, 2024, when a 12:30 AM bed check revealed that Resident #6, who had been admitted with traumatic brain hemorrhage and skull fracture, was missing from the facility. Staff discovered the resident had used a butter knife to break the lock on his bedroom window and escaped, leaving behind a note expressing his desire to leave the facility.
The resident, who scored 12 on the Brief Interview for Mental Status assessment indicating moderate cognitive impairment, had been identified as an elopement risk in his care plan. The plan, dated August 16, 2024 and revised on October 6, 2024, specifically noted the resident was "at risk for elopement related to cognitive impairment" and exhibited "unsafe wandering behaviors."
Medical records showed the resident required setup assistance with activities of daily living due to his traumatic brain injury sustained in July of the previous year. Despite these documented vulnerabilities and cognitive limitations, the facility's window security measures proved inadequate to prevent his escape.
Failure to Implement Adequate Security Measures
The facility's own policy on elopement risk stated that residents who exhibit unsafe wandering behavior must receive adequate supervision to prevent accidents. The policy defined elopement as when a resident leaves the premises without authorization or necessary supervision. However, the window locks in resident rooms were not sufficiently secure to prevent a cognitively impaired resident from defeating them with common utensils.
The Social Services Director documented multiple conversations with the resident on October 2nd, 3rd, and 4th, during which the resident repeatedly expressed his desire to leave and claimed he had secured housing in Kingsport. The director advised the resident that if he could wait until Monday, October 7th, they would facilitate a safe discharge. Despite these clear warning signs and the resident's documented elopement risk, no additional security measures were implemented for his room.
When investigators spoke with the facility Administrator on February 25, 2025, she confirmed that the resident "broke the lock on the window with a butterknife and went out the window." This demonstrates a fundamental failure in the facility's physical plant security, as standard window locks should be resistant to tampering by residents, particularly those identified as elopement risks.
Medical Implications of Unsupervised Elopement
The escape of a resident with traumatic brain injury and cognitive impairment presents severe medical risks. Individuals with moderate cognitive impairment often lack the judgment and decision-making capacity to navigate safely in the community. They may become disoriented, fail to recognize dangers, or be unable to seek help when needed.
Traumatic brain injury patients frequently experience confusion, memory problems, and impaired executive function. These deficits make them particularly vulnerable when unsupervised in the community. The combination of skull fracture history and cerebral hemorrhage indicates this resident had sustained significant neurological trauma that would affect his ability to make safe decisions or care for himself independently.
The resident's sister, contacted by telephone on February 26, 2025, confirmed these concerns, stating that her brother "had a traumatic brain injury in July of last year he couldn't care for himself so we put him in [the facility]." She reported receiving a call from a physician's office indicating the resident had appeared there on February 25, 2025, to reschedule a missed appointment, but his current whereabouts remained unknown.
Systemic Security Failures Identified
The facility's response after discovering the elopement revealed multiple systemic issues. While staff appropriately initiated elopement procedures including searching for the resident, securing exits, performing a head count, and notifying local police, these reactive measures came too late to prevent the incident.
The local Police Sergeant who responded to the call confirmed in a telephone interview that facility staff provided information about the missing resident and that investigators "determined he had escaped through the window." The fact that a cognitively impaired resident could defeat window security with a butter knife indicates inadequate assessment of physical plant vulnerabilities.
Following the incident, the Maintenance Director conducted comprehensive audits of all windows and doors throughout the facility on October 6, 2024. All center door codes were changed, doors were set to alarm when opened for more than 15 seconds, and were programmed to auto-lock upon closure. The window lock in the resident's former room was replaced. These corrective actions, while appropriate, should have been in place before the elopement occurred.
Additional Issues Identified
The investigation revealed several other concerning practices at the facility. A 100% review of all residents' elopement assessments conducted after the incident found that multiple assessments were not up to date or accurately reflected in care plans. This suggests the facility had not been consistently evaluating and addressing elopement risks across its resident population.
The facility instituted mandatory education for all staff on elopement prevention, the importance of maintaining privacy with door codes, and proper implementation of the Elopement Risk Policy. Staff were required to complete post-tests with 100% compliance, with re-education provided until this threshold was achieved. The need for this comprehensive retraining suggests previous training had been inadequate.
New signage was placed at the front entrance reminding people to ensure door locks had engaged and providing instructions to use the doorbell for staff assistance. The facility also began conducting monthly elopement drills on each shift, practices that should have been standard protocol for a facility serving residents with cognitive impairment and elopement risks.
Window audits were increased to weekly for four weeks, then biweekly for four weeks, before returning to monthly schedules. The Maintenance Director now performs manual checks on all windows to ensure latches are secured and that doors have proper functioning locks and alarms. These enhanced monitoring protocols indicate recognition of previous inadequate oversight of physical security measures.
Industry Standards and Regulatory Compliance
Nursing homes are required under federal regulations to ensure resident safety and provide adequate supervision based on individual assessments. The facility's failure to maintain secure windows for a known elopement risk represents a violation of these fundamental safety requirements. Standard practice in long-term care facilities serving residents with cognitive impairment includes tamper-resistant window locks, particularly in rooms housing residents identified as elopement risks.
The cognitive assessment score of 12 on the BIMS scale placed this resident in the moderate impairment category, indicating significant deficits in memory, decision-making, and safety awareness. Industry standards dictate that residents with these cognitive limitations require enhanced environmental safeguards and supervision protocols. Window locks that can be defeated with common utensils do not meet minimum safety standards for securing residents with documented elopement risks and cognitive impairment.
The facility's corrective action plan, while comprehensive, essentially acknowledged that basic safety measures were not in place before the incident. The implementation of door alarms, auto-locking mechanisms, and regular security audits represents the minimum standard of care that should have been maintained consistently, not instituted only after a serious elopement incident.
The Quality Assurance Performance Improvement committee now reviews window and door lock audits monthly, with any non-compliance issues triggering a return to more frequent monitoring. This ongoing oversight structure, involving the Administrator, Director of Nursing, Medical Director, and other department heads, reflects the level of attention that should have been devoted to security measures before a vulnerable resident escaped through an inadequately secured window.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Four Oaks Health Care Center from 2025-03-05 including all violations, facility responses, and corrective action plans.
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