BRANDON, MS - A state inspection at Brandon Nursing and Rehabilitation Center uncovered critical safety failures after a vulnerable resident with mental health conditions left the facility undetected and was discovered sitting in a staff member's vehicle in the parking lot on May 1, 2025.
Resident Left Building Unnoticed After Days of Exit-Seeking Behavior
The 79-bed facility failed to implement proper safeguards for a resident diagnosed with bipolar disorder, schizophrenia, and anxiety disorder who had displayed clear warning signs of attempting to leave for nearly a week before the incident occurred. According to inspection records, the resident began packing small bags with clothing and repeatedly approaching the facility's front door starting April 25, telling staff that family members were coming to pick her up.
Despite these documented behaviors continuing for six days, nursing staff failed to update the resident's care plan or implement any wandering prevention measures. The resident successfully exited through the main entrance on May 1 at approximately 3:00 PM during a receptionist's break. A certified nursing assistant discovered her sitting in his personal vehicle parked just 55 feet from the entrance when he went on break.
The temperature that day reached 81 degrees Fahrenheit, creating additional health risks for the unsupervised resident who was documented as requiring supervision for walking and being at fall risk.
Multiple Staff Members Observed Warning Signs Without Taking Action
Licensed Practical Nurse #9, assigned to the resident's care, documented the exit-seeking behaviors in progress notes dating back to April 24 but acknowledged during the inspection that she "had not updated the resident's care plan and there had been no orders for application of wander management device or other supervision resulting from the behavior until after the resident's elopement."
The facility's receptionist reported that on the day of the incident alone, the resident had approached the front entrance at least three times, requiring staff to redirect her back to her unit. The Social Services Director observed the resident's anxious behavior and repeated trips to the front hall throughout the day but failed to identify these as elopement risk factors.
Critical Safety Protocols Were Missing or Ignored
The inspection revealed systemic failures in the facility's elopement prevention system. The Elopement Binder, which should contain current information about residents at risk for wandering, was missing from the nurses' station. While 18 residents were identified as having wandering behaviors and at risk for elopement, proper monitoring protocols were not in place.
When individuals with cognitive impairment or psychiatric conditions exhibit exit-seeking behaviors, standard medical protocol requires immediate assessment and implementation of appropriate interventions. These may include wander guard devices, increased supervision, environmental modifications, or one-on-one monitoring. The facility's delay in implementing these measures for six days placed the resident at severe risk.
Elopement poses serious dangers for nursing home residents, particularly those with mental health conditions or cognitive impairment. Wandering residents face risks including exposure to extreme temperatures, traffic accidents, falls, dehydration, and becoming lost or disoriented. The facility's parking lot opened directly onto a four-lane boulevard with a 35-mile-per-hour speed limit and no crosswalks, where inspectors observed 125 vehicles passing in just five minutes.
Facility Failed to Follow Its Own Policies
The facility's own policy stated that "The Unit charge Nurse is responsible for knowing the location of their residents," yet staff were unaware the resident had left the building until she was discovered by chance. No head count was conducted after the incident to ensure other residents were accounted for, and no incident report was filed as required by standard protocol.
The Executive Director's decision not to report the incident to state authorities, claiming it wasn't an elopement because the resident mentioned her brother picking her up, contradicts established safety protocols. Any instance of a resident leaving a secured facility without proper authorization and supervision constitutes an elopement requiring immediate reporting and investigation.
Additional Issues Identified
The inspection also revealed that the facility lacked operational security cameras that could have helped monitor resident movements and investigate the incident. Staff had not participated in any elopement drills following the May 1 incident, indicating a failure to learn from the serious safety breach. The facility only conducted a trauma screen for the resident nine days after the elopement occurred, well beyond the timeframe for effective assessment of potential physical or psychological harm.
Only after the resident was found in the parking lot did the facility finally implement appropriate measures, including applying a wander guard device to the resident's ankle and initiating 72-hour one-on-one supervision. These interventions should have been implemented when exit-seeking behaviors first emerged, not after a potentially catastrophic incident had already occurred.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brandon Nursing and Rehabilitation Center from 2025-05-12 including all violations, facility responses, and corrective action plans.
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