The August incident triggered an immediate jeopardy citation from federal inspectors, who found the facility failed to follow its own policies designed to prevent residents from leaving undetected.
Resident #1 had been classified as high risk for elopement. His assessment clearly documented this danger, yet he managed to exit the building without any staff member signing him out or being aware of his departure.
The facility's own policy from August 2006 requires all residents leaving the premises to be signed out. Staff who observe residents leaving and have doubts about proper sign-out procedures must notify their supervisor immediately.
Another policy from 2001 instructs employees who see residents attempting to leave to prevent their departure courteously, get help from nearby staff if necessary, and inform the charge nurse that a resident is trying to leave or has left.
None of this happened.
The Administrator told inspectors the facility contacted local hospitals to inquire about the resident's whereabouts and was able to locate him. A police report was filed during the search.
After the incident but before inspectors arrived on August 13, the facility scrambled to implement corrective measures. On August 3, all staff received in-service training on resident sign-out procedures. The 2006 policy was attached for reference, and every employee signed acknowledgment forms.
That same day, Resident #1 received a physician's order stating he "has exit seeking behaviors" and required a "Wander Guard to be placed for resident safety" on his right wrist.
His care plan was updated August 3 to address "elopement risk/wander risk as evidenced by history of wandering off in last 30 days." The plan noted his "impaired safety awareness" and mandated the wander guard with specific interventions.
Staff were instructed to check the wander guard placement every shift to ensure it functioned properly on his right wrist. They were also required to visually inspect the device every two hours.
When inspectors arrived, they observed Resident #1 wearing the wander guard on his right wrist on August 13 at 11:37 am and again on August 14 at 2:20 pm.
The facility posted new signs by the entrance door and reception desk informing all visitors they must sign in upon entering and sign out when exiting.
During interviews, Resident #1 told inspectors on August 14 that he understood the need to sign out and notify nurses before leaving. He said he was "ok with wearing the wander guard in case he got confused and got out the facility, they would know and get him back inside."
He stated he felt safe inside the facility.
Seven staff members interviewed between August 13 and 14 confirmed they had received the August 3 in-service training on visitor sign-in and sign-out procedures. They told inspectors they now knew to ask residents if their nurses were aware of their outings and to confirm this with nursing staff.
The employees said they would reference an "elopement binder" located in the receptionist area and verify plans with nurses before allowing residents to leave.
Receptionist A, RN B, Receptionist C, the Business Office Administrator, LVN D, RN E, and LVN F all acknowledged the new procedures during inspector interviews.
The Administrator explained that the receptionist and all other staff had received training on signing in and out procedures. To prevent similar incidents, he said the facility implemented the sign-in/out process immediately after the elopement, placed Resident #1 on a wander guard, and updated his care plan and elopement assessment to reflect his escape risk.
The inspection revealed no other attempted or reported elopements in Resident #1's progress notes following the incident.
However, the damage was done. A vulnerable resident with documented wandering behaviors and impaired safety awareness had walked out of the facility unnoticed, requiring a police search to bring him back safely.
The immediate jeopardy citation reflects the serious risk this lapse posed to resident safety, particularly for someone already identified as high-risk for dangerous wandering behavior.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At El Paso from 2025-08-18 including all violations, facility responses, and corrective action plans.