WIBAUX, MT - A nursing home resident with severe cognitive impairment escaped three times in two weeks by climbing through windows, including one incident where staff discovered him snow shoveling in the courtyard after obtaining a shovel from an unlocked area.
Multiple Window Escapes Expose Security Failures
Wibaux County Nursing Home faced scrutiny during a March 2025 inspection after a resident with severe cognitive impairment escaped the facility three separate times through unsecured windows. The resident, identified as having a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment, demonstrated a pattern of window escapes that revealed significant gaps in the facility's security protocols.
The first documented incident occurred February 16, 2025, when the resident opened a dining room window and climbed out into the courtyard. Staff found him actively shoveling snow with a shovel he had obtained, wearing only a jacket, baseball hat, and medical gloves. Despite the resident's refusal to return until he finished his task, staff waited with him outdoors rather than implementing immediate safety measures.
One week later, on February 23, a second escape occurred when the resident crawled through his room window and headed toward the facility garage. Staff located and returned him within approximately 10 minutes without apparent injury. However, the most concerning incident happened February 27 when staff discovered the resident's open window and found him missing during a facility-wide search. He was eventually located behind the nursing home at a nearby clinic, where he had remained long enough to provide his phone number to clinic staff before facility personnel arrived.
The repeated nature of these escapes demonstrates the facility's failure to implement effective preventive measures. Federal regulations require nursing homes to identify residents at risk for elopement and implement appropriate monitoring and security interventions to prevent unsafe departures from the premises.
Critical Assessment and Documentation Delays
The inspection revealed troubling delays in completing required safety assessments following the elopement incidents. Federal regulations mandate immediate evaluation after any elopement to assess injury risk and implement preventive measures, yet the facility failed to complete elopement evaluations until March 10, 2025 - the first day of the federal inspection.
The February 23 elopement evaluation was not completed until 15 days after the incident, while the February 27 assessment remained incomplete for 11 days. This delay pattern indicates systemic problems with the facility's response protocols and documentation practices. More concerning, the facility performed no injury assessments following the first elopement, despite the resident being found outdoors in winter weather conditions.
Staff interviews revealed concerning gaps in understanding basic safety protocols. Three staff members failed to recognize window escapes as elopements, incorrectly believing that remaining on facility property meant the resident was not at risk. This fundamental misunderstanding of safety procedures suggests inadequate training on elopement prevention and response.
Window Security Measures Prove Ineffective
The facility's attempts to secure windows after the initial incidents demonstrated poor planning and execution. Initially, staff installed Velcro-based window stops that could be easily removed by residents. After the resident removed these devices and escaped again, the facility ordered more secure clamps requiring tools for removal, but many windows remained unsecured while waiting for properly sized equipment.
During the inspection, investigators found multiple security failures. Windows on the secure unit could be opened to 16 inches, with Velcro closures incorrectly installed in some rooms and completely removed in others. The television room and courtyard windows lacked any security devices despite being identified as potential escape routes.
Staff member monitoring protocols also proved inadequate. While 15-minute observation checks were implemented after the third elopement, staff acknowledged these intervals were often missed due to insufficient staffing. With only one staff member monitoring ten residents on the secure unit, gaps in supervision created ongoing safety risks.
Medical Risks of Unmonitored Departures
Elopement incidents pose serious health risks for nursing home residents, particularly those with cognitive impairment. Residents who leave secure areas without supervision face exposure to extreme temperatures, potential dehydration, disorientation, and injury from falls or vehicle accidents. The cognitive impairment that often drives elopement behavior also prevents residents from recognizing these dangers or seeking appropriate help.
Winter weather conditions during these February incidents created additional hypothermia and frostbite risks. Even brief exposure to cold temperatures can cause serious medical complications for elderly residents, particularly those taking medications that affect circulation or temperature regulation. The resident's minimal winter clothing during the snow shoveling incident could have resulted in serious cold-related injuries.
Residents with severe cognitive impairment may also experience increased confusion and agitation when removed from familiar environments. The stress of being lost or in unfamiliar surroundings can exacerbate underlying medical conditions and increase fall risk when residents attempt to navigate unfamiliar terrain.
Industry Standards for Elopement Prevention
Effective elopement prevention requires comprehensive assessment, environmental modifications, and individualized monitoring strategies. Best practices include immediate risk assessment upon admission, regular reassessment throughout residency, and prompt implementation of preventive measures for at-risk residents.
Environmental modifications should include secure window and door systems that cannot be easily bypassed by residents while maintaining fire safety compliance. Many facilities use magnetic door alarms, pressure-sensitive floor mats, or wearable tracking devices to monitor resident movement and alert staff to potential elopement attempts.
Individualized care plans should address the underlying causes of elopement behavior, such as searching for family members, attempting to return home, or responding to hallucinations or delusions. Effective interventions often include structured activities, familiar objects from home, and consistent staff assignments to reduce anxiety and confusion that may trigger elopement attempts.
Broader Safety and Compliance Issues
The inspection identified additional safety concerns beyond elopement risks. Two residents had bed rails installed without proper risk-benefit assessments, despite taking psychotropic medications that could increase entrapment dangers. Staff failed to consider medication effects or explore alternative fall prevention strategies before implementing these potentially dangerous devices.
The facility also operated with an uncertified dietary manager for over a year despite ongoing compliance requirements. This staffing deficiency affects residents' nutritional care and food safety, as certified dietary managers receive specialized training in therapeutic nutrition and food service safety protocols essential for vulnerable elderly populations.
Additional Issues Identified
Inspectors documented incomplete medical records affecting five residents, including invalid advance directive forms and delayed assessment completions. One resident's care plan contained inappropriate personal information about staff members' spouses rather than medically relevant care instructions.
The facility's assessment processes showed systematic delays, with one resident's elopement risk evaluation completed 14 days after admission rather than within the required timeframe. These documentation failures compromise care coordination and regulatory compliance monitoring.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wibaux County Nursing Home from 2025-03-13 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.