JACKSON, MS - A cognitively impaired resident at Chadwick Nursing and Rehabilitation Center left the facility undetected through an unsecured kitchen door on May 9, 2025, and was discovered approximately one mile away walking near a busy four-lane highway, according to a state inspection report. The 76-year-old resident, who had been identified as an elopement risk and was wearing a functioning wander guard bracelet, remained missing for nearly two hours before staff located him.
Critical Security Breach in Kitchen Area Allows Resident to Exit Undetected
The inspection revealed that the resident accessed an unsecured staff door leading into the kitchen area around 7:30 AM, then exited through a loading dock door that lacked a wander guard sensor system. This represented a fundamental breakdown in the facility's security protocols, as all other exterior doors were equipped with alarm systems designed to alert staff when residents wearing wander guard bracelets approached.
The resident had been admitted to the facility on April 1, 2025, with a diagnosis of schizophrenia and was assessed as severely cognitively impaired with a Brief Interview for Mental Status score of 4. Despite physician's orders dated April 4 for daily wander guard monitoring and shift-by-shift verification of the device's functionality, the security gap in the kitchen area rendered these precautions ineffective.
According to facility staff interviews, the resident was last observed in the dining room at approximately 7:30 AM, seated at a table near the entrance to the kitchen area with his walker beside him. A dietary aide who had been delivering breakfast trays noticed the resident was no longer at the table when she turned around, though his walker remained in place. The aide received a phone call from the resident's daughter at approximately 7:45 AM regarding a scheduled doctor's appointment, and it was at this point that staff realized the resident was missing.
Two-Hour Search Ends with Resident Found in Dangerous Location
The facility initiated a "Dr. Wander" alert at approximately 7:45 AM, mobilizing all available staff to search the premises and surrounding areas. Multiple staff members, including nurses, certified nursing assistants, housekeeping, and administrative personnel, participated in the search both inside the facility and in the surrounding neighborhood.
The resident was finally located at 9:20 AM by two staff members who spotted him walking in a grassy area adjacent to a busy four-lane highway near a local bank, approximately one mile from the facility. The resident's son, who had been contacted by his sister and was conducting his own search, arrived at the location simultaneously. The son later stated in an interview that he was "shocked that his father had managed to cross the highway safely."
When found, the resident was alert, oriented to his name, and fully dressed in appropriate clothing including a white t-shirt layered with a long-sleeved shirt, long pants, and laced tennis shoes. A head-to-toe assessment conducted upon his return to the facility at 9:32 AM revealed no signs of injury, distress, or trauma. The resident told staff he was "just trying to go home" and confirmed he had exited through the kitchen door.
Pattern of Exit-Seeking Behavior and Systemic Monitoring Failures
The inspection uncovered that this incident was not an isolated occurrence of exit-seeking behavior. Multiple staff members reported observing the resident attempting to leave through various doors since his admission. A housekeeping staff member specifically recalled seeing the resident standing at the front door with his walker at approximately 5:45 AM on the morning of the elopement, attempting to exit the building. While the wander guard alarm activated and the employee redirected the resident, no nursing staff were notified of this earlier attempt.
The failure to recognize and respond to this pattern of behavior represents a significant lapse in resident monitoring and communication among staff. Exit-seeking behavior in residents with dementia and cognitive impairment requires comprehensive intervention strategies, including environmental modifications, increased supervision, and coordinated staff responses. The progression from attempted exits to successful elopement within a three-hour window demonstrates the facility's failure to implement adequate preventive measures despite clear warning signs.
The resident's cognitive status, with a BIMS score indicating severe impairment, should have triggered heightened vigilance and more restrictive safety measures. Facilities caring for residents with severe cognitive impairment must implement multi-layered security protocols that account for the unpredictable nature of confused residents who may not comprehend the dangers they face when leaving a secure environment.
Medical Risks and Potential Consequences of Unsupervised Elopement
The dangers associated with cognitively impaired residents leaving a secure facility cannot be overstated. Residents with severe cognitive impairment lack the judgment and awareness necessary to navigate safely in community settings. They may be unable to recognize traffic hazards, become disoriented and unable to find their way back, or experience medical emergencies without access to their prescribed medications or necessary care.
In this case, the resident crossed a busy four-lane highway with turning lanes and multiple traffic lights during heavy morning traffic. The risk of vehicular injury or death was substantial. Additionally, the resident went without his morning medications for the duration of his absence, potentially destabilizing his psychiatric condition and increasing confusion and agitation.
Exposure to environmental elements poses another significant risk. While this incident occurred in May with mild weather conditions, elderly residents are particularly vulnerable to temperature extremes, dehydration, and physical exhaustion. The resident was found after walking approximately one mile, and his daughter confirmed he appeared "tired" upon his return to the facility.
The psychological impact of such incidents extends beyond physical risks. Residents with cognitive impairment may experience increased anxiety, fear, and disorientation following an elopement event. Family members also experience significant distress, as evidenced by the resident's daughter and son who immediately left their obligations to join the search effort.
Additional Issues Identified
The inspection report documented several other deficiencies that contributed to this serious incident. Staff failed to maintain constant awareness of resident locations, as required by facility policy stating that unit charge nurses and certified medication technicians must know the whereabouts of their assigned residents at all times. Communication breakdowns between departments meant that critical information about the resident's exit-seeking behavior earlier that morning was not shared with nursing staff.
The facility's elopement response protocol, while eventually activated, experienced delays as staff initially searched individually before initiating the formal alert system. Documentation practices were also inadequate, with inconsistent recording of wander guard checks and exit-seeking behaviors in the days leading up to the elopement.
Environmental assessments had failed to identify the security vulnerability in the kitchen area, despite the facility having conducted previous reviews of exit doors and alarm systems. The loading dock door's keypad lock proved insufficient as a standalone security measure for preventing confused residents from exiting.
Following the incident, the facility implemented numerous corrective actions including installation of wander guard sensors on all previously unsecured doors, one-on-one supervision for the affected resident, comprehensive staff re-education on elopement prevention, and mock elopement drills for all shifts. The resident was relocated to a room closer to the nursing station, and his care plan was updated to reflect his high elopement risk.
The facility also initiated new protocols requiring daily review of progress notes for any residents expressing desires to leave or exhibiting exit-seeking behavior. A quality assurance meeting was convened immediately following the incident, and formal communication was sent to all resident representatives regarding the importance of notifying staff when residents express wishes to leave during visits.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chadwick Nursing and Rehabilitation Center LLC from 2025-05-14 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.