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The facility failed to maintain sanitary food preparation and service while contractors excavated a large hole in the kitchen floor near the steamer and tray line. Unsecured plastic barriers, exposed dirt piles, broken tile, rocks, wastewater, and contractor traffic with dirty boots were present in the food prep area, while garden hoses ran from the kitchen through the dining room and out an open window. Dietary staff continued to prep and serve meals from a steam table and work areas located directly next to the open excavation, with wrapped silverware and disposable items stored near dirt and debris, and a soiled blender left on a dining room table. The CDM, DONs, Maintenance Director, and Administrator all acknowledged that the barrier was not verified as secure and that food preparation was not removed from the contaminated kitchen, resulting in multiple meals being served under these conditions to all residents who ate from the kitchen.
A resident with quadriplegia and intact cognition asked a CNA to retrieve food, and the CNA responded angrily, yelling that the resident would not receive anything from him and charging toward the resident with aggressive body language. The resident, in a slow electric wheelchair, reported feeling scared and unsafe, and another resident witnessed the incident. Over subsequent days, the resident showed emotional distress, stayed in bed, avoided social interaction, and told staff she did not feel safe with the CNA. Although multiple staff later described the CNA’s conduct as verbal or emotional abuse, the charge nurse and CNA who first received the complaint did not report it to the administrator as abuse, the administrator did not interview the resident, and the incident was not reported to state authorities or investigated as abuse for several days. During this delay, the CNA, who had known behavioral issues and had been described as rude, resistant, and prone to shouting at residents, continued to be assigned to provide care to dozens of other residents on two units, contrary to facility abuse policies requiring immediate reporting, prompt investigation, and removal of accused staff from resident care.
A resident with cerebral palsy, severe mobility limitations, and high fall risk required two-person assistance with a mechanical lift, but a CNA attached the sling to a handling strap instead of the proper attachment loop during a transfer, causing the resident to fall and sustain a fractured clavicle. The resident reported that only one staff member performed the transfer, despite her usual two-person assist requirement, and later experienced pain with a replacement sling during subsequent transfers. Surveyors found no documented mechanical lift competencies for CNAs or nursing staff, and the DON and DOR were unable to demonstrate or clearly explain safe lift use, sling inspection responsibilities, or how competencies were validated. Observations of additional transfers showed CNAs failing to center the sling and manage lift wheels correctly, and multiple staff could not describe required safety measures, leading to an Immediate Jeopardy finding for failure to ensure competent nursing staff for mechanical lift transfers.
A resident with cerebral palsy, severe mobility limitations, and high fall risk required two-person mechanical lift transfers per the care plan. During a transfer, a CNA attached the lift sling to a handling strap instead of the designated attachment loop, causing the strap to break and the resident to fall, resulting in a fractured clavicle confirmed by X-ray and CT. The resident reported that only one staff member was performing the transfer initially and that pain began immediately after the fall. Post-fall, another sling was used, and the resident later described severe leg pain with transfers using the replacement sling. Interviews with the Administrator and DON revealed unclear systems for training, competency validation, and inspection of lift slings and straps, and the DON could not identify who was responsible for or the frequency of sling and lift safety inspections. An Immediate Jeopardy was cited for failure to ensure adequate supervision and proper use of assistance devices during mechanical lift transfers.
Two residents with moderate cognitive impairment and known wandering risk eloped multiple times without staff knowledge. One resident, with heart failure, gait abnormality, and a history of falls, removed a wander guard bracelet, exited through the main entrance while the receptionist was on break, and was later found in the parking lot with a facial laceration; the same resident later left the therapy gym unsupervised and again exited through the lobby when no staff were monitoring the entrance. Another resident, with metabolic encephalopathy, schizophrenia, PTSD, and a history of wandering to find family, left the building and was first kept within sight in the parking lot, then on a later occasion eloped again and was found at a distant security gate in another resident’s car, with staff unable to state when she was last seen. Observations showed that wander guard alarms were difficult to hear amid noise and that basement exits and loading dock doors were unlocked and unsupervised, allowing access to the outside despite existing elopement policies and use of wander guard devices.
Unsanitary Food Preparation During Kitchen Plumbing Excavation
Penalty
Summary
The deficiency involves the facility’s failure to prepare and serve food under sanitary conditions while major plumbing repairs and floor excavation were occurring in the kitchen. After an underground water line break affecting the kitchen and laundry, contractors began digging a large hole in the kitchen floor near the steamer and tray line. Temporary plastic barrier walls were placed, but they were unsecured and had open areas. Surveyors observed garden hoses running from the kitchen across the dining room floor and out an open window, with hoses duct-taped to the floor. The kitchen floors were heavily soiled with boot prints, and contractors walked through the food prep area, tracking dirt. Large piles of dirt, broken tile, concrete, rocks, and wastewater were present near the tray line, stovetop, and three-compartment sink. Despite these conditions, the facility continued to prep and serve meals from the kitchen. Dietary staff were observed serving food from a steam table located directly next to the unsecured plastic barrier and large open holes in the floor with exposed dirt and debris. Prepped and wrapped silverware was stored on the steam table within about two feet of the large hole and dirt piles. Cardboard boxes of disposable meal service items were placed directly on the kitchen floor near the tray line. A soiled blender was observed on a dining room table next to personal drinks and a soiled towel. The Certified Dietary Manager (CDM) stated that after the first hole was dug following breakfast, all subsequent meals continued to be prepped and served in the kitchen next to the excavation area, and that food had been taken back and forth from refrigerators located beyond the barrier and past the large hole. Multiple staff interviews confirmed that the barrier was not effectively monitored or verified as secure. The Maintenance Director acknowledged that he did not verify that the plastic barrier wall was secured or check it frequently, and that a wet saw was used to cut through floor tiles, which created dust. The DON stated that if the barrier was broken open there was a risk of pathogens contaminating the food and that, because the barrier was not sealed, food should not have been prepared in the kitchen. The previous DON reported she knew digging was occurring in the kitchen but did not enter the kitchen initially, assumed there was a barrier, and believed food preparation had been moved out of the kitchen without confirming this. The Administrator stated she saw the barrier closed but did not order food preparation to be removed from the kitchen and did not assign anyone to monitor the barrier. From the time the hole was dug until surveyor intervention, 10 meals were served out of the kitchen under these unsanitary conditions, affecting all residents who ate meals prepared there.
Removal Plan
- Facility plans to use prepared food from a US food vendor for upcoming meals as a back-up plan.
- Facility is using disposable paper products immediately as a back-up plan.
- Facility discarded all lunch that was ordered for residents and stopped lunch trays enroute to the units; lunch was catered in for the residents.
- Dietician and Medical Director were notified of the Immediate Jeopardy.
- The kitchen immediately closed for services.
- The dining room next to the kitchen is being set up as the temporary kitchen until pipe work and construction are completed.
- The juice machine, coffee maker, steamer, steam table, tray line, prep area, 3-compartment area, and handwashing station are being utilized in the temporary kitchen.
- All residents who eat meals were immediately assessed for food borne illness.
- All residents at risk for food borne illness.
- A temporary refrigeration truck is providing both freezer and refrigeration.
- An electrician inspected for the correct plug for the steamer, rewired to accommodate the steamer in the temporary kitchen, and cleared it for use.
- The steam table was disinfected after removal from the construction zone.
- A handwashing station was delivered and set up in the temporary kitchen.
Failure to Protect Resident From Mental Abuse and Delay in Abuse Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident with quadriplegia from mental abuse and intimidation by a CNA, and failure to recognize, report, and investigate the incident as abuse. The resident, who used a slow-moving electric wheelchair and had a BIMS score of 15/15, asked a CNA to retrieve food from a refrigerator. The CNA responded by demanding that the resident say hello to him if she wanted something, repeating this in an angry manner. When the resident replied that she did not have to say hello if she did not want to, the CNA turned, yelled that if she did not say hello she would not get anything from him and would have to call her assigned CNA, and then charged toward her with his chest out and aggressive arm movements. The resident reported feeling scared and defenseless because of her limited mobility and slow wheelchair, and believed the CNA appeared as if he wanted to physically fight her. A second resident witnessed the incident and corroborated the account. Following the incident, the resident called for help and reported to another CNA and the charge nurse that she was scared and did not feel safe with the CNA’s behavior. Staff observations and progress notes documented that the resident appeared in emotional distress at the time of the incident and remained upset and distressed over the following days, including expressing disbelief that the incident had occurred, stating she was not safe with the CNA, and planning to report to the police and Ombudsman. She stayed in bed for several days, refused to get out of bed, avoided social interaction, and declined to keep talking about the incident because she did not want to be retraumatized. Social work and psychotherapy notes documented that she did not feel safe with the CNA, feared he could lose his temper with her or other residents, and that the interaction elicited feelings of unsafety, a sense of being frozen, and led to three consecutive days in bed and avoidance of social interaction. Despite these reports and observations, the charge nurse and CNA who first received the resident’s complaint did not report the incident to the administrator as an allegation of abuse, and the administrator did not interview the resident. The administrator stated she did not consider the incident to be abuse and believed the resident had chosen to file an internal grievance rather than have the incident reported externally. Nursing supervisors did not relay the resident’s statements of fear and emotional distress to the administrator, and one supervisor reported only the CNA’s version of events, omitting the resident’s account. The facility did not complete and submit the SOC 341 abuse report form or report the allegation to the state agency until three days after the incident, and the internal investigation did not begin until that time. During this delay, the CNA, who had a documented history of behavioral concerns noted by the Directors of Staff Development and other staff (including arrogance, resistance to instruction, rudeness, shouting at residents, and unprofessional conduct), continued to be assigned to provide care to residents on two other units, exposing 63 residents to a staff member whose conduct toward the resident had been described by multiple staff as abuse and emotionally distressing. The facility’s own policy defined mental abuse as verbal or nonverbal conduct causing or having the potential to cause humiliation, intimidation, fear, or degradation, including yelling, hovering to intimidate, threatening residents, and depriving a resident of care. Staff interviews, including those of CNAs, the charge nurse, social worker, and Directors of Staff Development, characterized the CNA’s conduct toward the resident as verbal or emotional abuse and intimidation. The facility’s abuse policy required all employees to act as mandated reporters, to immediately report suspected abuse to the administrator and external agencies within specified time frames, to initiate an investigation promptly, and to ensure that staff accused of abuse generally did not have contact with residents during the investigation. These requirements were not followed in this case, leading to a failure to protect the resident from mental abuse and intimidation and a failure to protect other residents from potential abuse. Surveyors determined that this failure to identify and act on the resident’s allegation as abuse resulted in psychosocial harm to the resident, including feeling scared and unsafe, withdrawal from socialization, and ongoing worry, and posed an immediate jeopardy to the safety and well-being of the other residents on the units where the CNA was assigned during the delay in reporting and investigation.
Removal Plan
- Immediately remove any staff member identified as the subject of an allegation involving intimidation, fear, or potential abuse from direct resident care pending investigation.
- Confirm through facility leadership that no residents are currently exposed to staff under investigation.
- Observe the affected resident by nursing staff after the incident and place the resident on monitoring for emotional distress every shift.
- Have the Behavioral Health Program Coordinator attempt to see/assess the affected resident (with follow-up attempts as needed).
- Provide access to facility psychologist and social workers to the affected resident (and all residents) as needed.
- Regardless of investigation type (complaint vs. abuse), if a staff member is an alleged perpetrator, remove the staff member from direct patient care pending abuse investigation results or determination the complaint does not involve abuse.
- Require staff reporting incidents to the Abuse Coordinator to provide thorough and accurate statements based on gathered knowledge, observations, preliminary interviews, and the resident’s psychosocial disposition.
- Report allegations or suspicions of abuse promptly according to required regulatory timelines and submit Form SOC 341.
- Educate staff that they are mandated reporters with the right and obligation to report abuse or suspicion of abuse regardless of others’ opinions.
- Ensure staff are educated and have access to the SOC 341 form and abuse policies/procedures for guidance.
- Provide facility-wide in-service education on staff training for abuse, neglect, and exploitation prevention, with staff on days off/leave/PTO completing education upon return and prior to providing patient care.
- Continue a thorough investigation of the allegations, including resident interviews, staff interviews, witness interviews, employee personnel file review, resident record review, and other items as necessary.
- Submit all investigation results to CDPH within required timelines.
- Have the Administrator/Abuse Coordinator review abuse investigation protocols using the Abuse Investigation Checklist with the Assistant Administrator, DON, ADON, QA nurse, other ADON, and the Behavioral Health Program Coordinator before assuming direct patient care.
Failure to Ensure Competent Mechanical Lift Use Resulting in Resident Fall and Fractured Clavicle
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff, including CNAs and nursing leadership, possessed and demonstrated the competencies and skills necessary to safely perform mechanical lift transfers. A cognitively intact female resident with cerebral palsy, significant mobility limitations, muscle weakness, contractures, and a high fall risk score required two-person assistance with a mechanical lift for transfers per her care plan. Her care plan also directed staff to ensure mechanical lift straps were secure, intact, and that all straps were in place before transfer. Despite these requirements, the resident was transferred in the early morning hours by a CNA who did not follow proper sling attachment procedures. During a mechanical lift transfer from bed to chair, the CNA attached the lift sling to the handling strap instead of the designated sling attachment loop. The resident fell from the lift during this transfer and was found on the floor on her back. She initially denied pain, and no immediate skin discoloration was observed, but later developed bruising and pain in the left shoulder. X‑ray and CT imaging confirmed a fractured clavicle. The resident reported that usually two staff assisted with mechanical lift transfers, but on the day of the fall she believed only one CNA performed the transfer and that the CNA was attempting to get her out of bed early without obtaining a second staff member. She also reported that after the incident, a new sling used for transfers caused her significant pain in her right leg during each transfer, and she did not feel safe when that sling was used, although she had not reported this concern to the facility. Interviews and observations revealed broader competency failures beyond the single incident. The Administrator identified the root cause of the fall as staff error related to improper sling attachment. The DON was unable to demonstrate proper mechanical lift use, did not lock the lift wheels, did not correctly position the sling, and could not clearly explain required safety measures or the system to ensure proper lift use, sling inspection, or frequency of equipment checks. The DOR, who provided an in‑service on mechanical lifts after the incident, stated he had not been trained on the specific lifts and slings used in the facility, was unfamiliar with manufacturer models and sling compatibility, and had not used the facility’s mechanical lift competency and evaluation checklist. Multiple CNAs and nurses reported they had been in‑serviced on mechanical lift transfers but denied completing any competency validation and were unable to clearly explain or demonstrate proper mechanical lift and sling use during surveyor observation. Record review showed no documentation that CNAs or other direct care staff, including the DON, had demonstrated competency in mechanical lift transfers prior to performing resident care, and there was no structured system to verify staff competency or to identify which residents required mechanical lift transfers. During an observed transfer of the same resident by two CNAs, staff again failed to demonstrate proper mechanical lift technique. They did not ensure the lift wheels were unlocked prior to sling attachment and did not center the sling under the resident before transferring her from chair to bed. The resident reported pain associated with improper positioning during this transfer. Staff interviewed during the survey could not clearly explain required safety measures for mechanical lift use. These findings, combined with the lack of documented competencies, unclear responsibility for sling and lift inspection, and leadership’s inability to describe or demonstrate safe transfer procedures, showed that the facility failed to ensure nursing staff had the appropriate competencies and skill sets to safely perform mechanical lift transfers, resulting in a resident fall with a fractured clavicle and placing other residents who required mechanical lift transfers at risk for serious injury. An Immediate Jeopardy was identified related to this deficiency, based on the lack of competency validation and improper sling attachment that led to the resident’s fall and injury. The facility did not have documentation verifying that direct care staff or supervising nursing staff had demonstrated competency in mechanical lift transfers prior to performing resident care, and there was no record identifying the number of residents requiring mechanical lift transfers. Leadership interviews showed that the Administrator, DON, and DOR were unclear about training systems, competency tracking, and responsibility for equipment inspection. These conditions contributed to the improper use of the mechanical lift and sling that caused the resident’s fractured clavicle and placed other residents requiring mechanical lift transfers at risk for serious injury, including fractures, head trauma, internal injury, or death, as stated in the report.
Removal Plan
- Administrator/DON/Corporate Nurse reviewed the Safe Handling of Resident Transfers policy.
- Assess resident; notify appropriate parties; send resident to hospital for further evaluation as indicated; schedule follow-up appointment as indicated; continue monitoring for injuries/changes in condition.
- Corporate Nurse to re-educate nursing staff directly involved in the resident’s fall before performing direct care on safe resident transfers using mechanical lifts, emphasizing proper securing of lift pad straps and inspection of straps/condition per manufacturer instructions; validate via facility mechanical lift competency checklist.
- Place manufacturer instructions for mechanical lift sling inspection on each mechanical lift for employee reference.
- Corporate Nurse to re-educate the DON and DOR on safe resident transfers using mechanical lifts, emphasizing proper securing of lift pad straps and inspection of straps/condition per manufacturer instructions; validate via facility mechanical lift competency checklist.
- DON/designee to review care plans for residents who use mechanical lifts to ensure appropriate transfer status is identified in the care plan.
- IDT to review new admissions in morning clinical meeting to identify transfer needs and care plan these needs.
- IDT to discuss residents with change in condition affecting mobility status and update transfer status and care plan as appropriate.
- Place care planned interventions including transfer status on the resident Kardex so direct care staff can view resident-specific needs.
- Educate nursing and therapy staff before performing direct care to review the Kardex to identify resident-specific needs.
- Corporate Nurse/Consultant Nurse to educate DON/ADON/Administrator on the facility orientation checklist for nursing staff; validate via facility mechanical lift competency checklist.
- Include mechanical lift/sling training at orientation for new nurses and nurse aides; complete training prior to staff transferring a resident using the lift/sling.
- Corporate Nurse, DON, DOR or designee to re-educate nursing staff and therapy staff before performing direct care on appropriate transfer and safe handling during mechanical lift transfers, emphasizing proper securing of lift pad straps and inspection of straps/condition per manufacturer instructions; validate via facility mechanical lift competency checklist.
- Administrator or DON to sign off that new nursing staff have completed the orientation checklist including validation of competencies prior to being moved from orientation status.
- DON/designee to audit mechanical lift transfers twice weekly for a specified period, then weekly for a specified period, then monthly for a specified period.
- Administrator to implement a QAPI PIP to gather/process information from monitoring rounds and report findings at the monthly QAA meeting.
Improper Mechanical Lift Use and Inadequate Supervision Resulting in Resident Fall and Clavicle Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and proper use of assistance devices during a mechanical lift transfer, resulting in a fall and injury to a resident. The resident was an adult female with cerebral palsy, abnormalities of gait and mobility, muscle wasting and atrophy, generalized muscle weakness, and joint contractures. Her MDS showed a BIMS score of 14, indicating no cognitive impairment, and a fall risk assessment score of 22, indicating high risk for falls. Her care plan identified her as at risk for falls related to limited mobility, weakness, and altered mental status, with a goal to remain free of falls and injuries. Interventions included use of a mechanical lift with two-person staff assistance for transfers and ensuring mechanical lift straps were secure, intact, and that the lift was charged before transfer. On the date of the incident, the resident was being transferred from bed using a mechanical lift by CNA G, with conflicting accounts about whether a second staff member was present at the time of the transfer. The resident reported that only one staff member was performing the transfer initially and that a second CNA arrived after the fall to get the nurse. During the transfer, CNA G attached the mechanical lift sling to the handling strap instead of the designated sling attachment loop. The sling strap then broke during the transfer, causing the resident to fall from the lift to the floor. The resident immediately experienced pain and reported it to the nurse. The facility’s Administrator later determined through investigation that the root cause of the incident was staff error in attaching the sling to the wrong part of the lift. Following the fall, the nurse on duty assessed the resident, who at first denied pain and showed no immediate discomfort or visible skin discoloration. The resident was found on her back on the floor with the sling under her body. The nurse was informed that the sling strap had broken during the transfer and that another sling was used to transfer the resident back to bed after the incident. Later that morning, the resident reported pain, and bruising was observed near the left shoulder. An X-ray performed at the facility revealed a fractured clavicle, which was confirmed by hospital imaging as a fracture of the distal end of the left clavicle. Interviews with the Administrator and DON showed they could not clearly explain how staff training on mechanical lift use was tracked, how competencies were validated, or who was responsible for inspecting slings and straps for safety or how often such inspections occurred. These actions and inactions led to the unsafe transfer, fall, and resulting clavicle fracture. In addition, after the incident, the resident reported that the facility replaced the sling and that the new sling caused significant pain, described as a knife-stabbing sensation to her right leg during each transfer. She stated she did not feel safe when the new sling was used and had not notified the facility of this concern. The report notes that the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, specifically citing the improper attachment of the sling by CNA G and the lack of clear systems for training, competency validation, and equipment inspection by facility leadership. An Immediate Jeopardy was identified related to this failure, and the facility remained out of compliance at a level of potential for more than minimal harm. The DON stated he was responsible for ensuring nursing staff were skilled and knowledgeable about mechanical lift safety but was not aware if the DOR had been informed of the fall incident. He could not explain who was responsible for inspecting slings and straps or how often mechanical lifts and slings were inspected for safety. The Administrator stated that all direct care staff were responsible for ensuring mechanical lift slings were safe and used properly, and that the DON was responsible for ensuring all direct care staff were trained by the DOR, but he was not aware how the DON tracked training and compliance. These gaps in oversight and unclear responsibilities contributed to the failure to ensure safe mechanical lift transfers and adequate supervision for the resident.
Removal Plan
- Corporate Nurse will provide re-education to nursing staff directly involved in the resident's fall on safe resident transfers when utilizing mechanical lifts, emphasizing proper securing of residents with mechanical lift pad straps and inspecting straps for safety prior to use per manufacturer instructions; education validated via facility mechanical lift competency checklist.
- Manufacturer instructions for mechanical lift sling inspection will be placed on each mechanical lift for employee reference.
- Corporate Nurse will provide re-education to the DON and DOR on safe resident transfers when utilizing mechanical lifts, emphasizing proper securing of residents with mechanical lift pad straps and inspecting straps for safety prior to use per manufacturer instructions; education validated via facility mechanical lift competency checklist.
- DON/Designee will review care plans for residents who use mechanical lifts to ensure appropriate transfer status is identified in their care plan.
- IDT will review new admissions in the morning clinical meeting to identify transfer needs and care plan these needs.
- IDT will discuss residents with a change in condition affecting mobility status and update transfer status and care plan as appropriate.
- Care planned interventions, including transfer status, will be placed on the resident Kardex so direct care staff can view resident-specific needs.
- Corporate Nurse/Consultant Nurse will educate the DON/ADON on the facility orientation checklist for nursing staff; education validated via facility mechanical lift competency checklist.
- Corporate Nurse, DON, DOR or designee will re-educate nursing staff and therapy staff on appropriate transfer and safe handling of residents during mechanical lift transfers, emphasizing proper securing of residents with mechanical lift pad straps and inspecting straps for safety prior to use per manufacturer instructions; education validated via facility mechanical lift competency checklist.
- DON or designee will audit mechanical lift transfers.
- A QAPI PIP will be initiated to report on the monitoring and auditing procedures.
- All findings from the PIP will be presented at the monthly QAA meeting.
- Monitoring/auditing and reporting will continue.
Failure to Prevent Multiple Elopements of Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for two residents assessed as elopement risks with moderate cognitive impairment. One resident (R14) had diagnoses including heart failure, acute respiratory failure, abnormality of gait, and a history of falls, and was care planned for wandering with interventions such as use of a wander guard/location monitor and redirection. An elopement assessment identified this resident as having wandering behavior occurring one to three days, at risk for getting to a dangerous place, with worsening behaviors and aimless wandering. Despite this, the resident’s quarterly MDS did not identify wandering behaviors, and the resident was able to remove the wander guard bracelet and leave the building without staff knowledge. In the first elopement event for R14, a utility staff member observed the resident outside in the front parking lot next to his wheelchair, with a bruise and laceration under his right eye. The wander guard bracelet was later found in the resident’s laundry bin, and the resident reported that he had intentionally removed the bracelet because it was uncomfortable and waited until no one was looking so he could go outside. The receptionist, who normally monitored the main entrance, was on break and did not see the resident exit. LPN1 confirmed that the resident had rolled his wheelchair out the door to the front parking lot and that the resident had begun exhibiting increased wandering and exit-seeking behaviors. In the second elopement event for R14, the admission coordinator noticed the resident sitting outside the facility in his wheelchair without staff supervision and redirected him back inside. Investigation showed that a CNA had taken the resident to the therapy gym and informed the PTA, then left after confirming the resident was still in therapy 15 minutes later. When therapy was completed, the PTA placed the resident back in his wheelchair and allowed him to return on his own, not being aware that the resident was a wanderer and not recalling a wander guard bracelet. The resident then turned toward the lobby instead of his unit and exited through the main entrance while the receptionist was again on a scheduled break. The second resident (R59) had diagnoses including metabolic encephalopathy, schizophrenia, anxiety, delusional disorders, PTSD, and abnormality of gait and mobility, with a BIMS score indicating moderate cognitive impairment. The care plan identified potential for falls and wandering, with interventions including monitoring for wandering behavior, redirection, keeping side doors locked, monitoring placement of a wander guard bracelet, and offering 1:1 staff when indicated. A wandering/elopement risk assessment documented a history of wandering to find family or a pet, cognitive impairment, and a recent medication change to decrease behaviors, and led to the decision to add an elopement deterrent device and develop an elopement care plan. For this resident, an earlier elopement incident involved leaving to the parking lot while fixated on finding her daughter, though staff kept her within constant sight and within about 10 feet. A later elopement involved the resident leaving the facility without staff knowledge and being found at a security gate approximately a mile from the entrance, sitting in the passenger seat of an independent living resident’s car. Staff statements indicated they did not see the resident leave and could not identify when she was last observed. It was suspected that she had followed a family or staff member out a side hall door closest to the guard house and main road. LPN2 reported that the resident wore a wander guard bracelet and frequently tried to remove it but did not know where the resident went or where she was found. Additional observations showed that the wander guard alarm for R14’s wheelchair produced an audible alarm that could be hard to hear at the nurses’ station when there was a lot of noise, even though it also displayed on monitors. An elevator near the nurses’ station led to a basement hallway where a second wander bracelet alarm was present, but no staff were in that area during observation. This basement hallway led to an unlocked exit door to the outside and another unlocked door to a loading dock and ramp leading outside. The facility’s elopement policy defined elopement as a resident wandering away without staff knowledge, out of visual sight, and being incapable of finding their way back, and required immediate, coordinated response when a resident was reported missing. The events described showed that both residents were able to exit the facility or reach unsecured areas without staff awareness, despite identified elopement risk and existing policies and interventions. This deficient practice resulted in the identification of Immediate Jeopardy and substandard quality of care at F689, with the Immediate Jeopardy beginning when R59 eloped from the facility and was later found at the security gate in another resident’s car.
Removal Plan
- Provide education to the Director of Nursing, Director of Social Services, the Minimum Data Set Coordinator for the risk of wandering.
- Record assessments in the resident's medical record.
- Identify residents at risk for wandering.
- Maintain wander guards for residents identified to need them.
- Check all external and lobby doors within the health and rehabilitation center to ensure that all doors are secured or have a wander guard system in place.
- Place a staff member to continuously supervise and monitor the lobby area outside of the health and rehab center lobby, elevator, and unsecured areas.
- Maintain supervision of this area until a wander guard is placed to ensure no access to an unsupervised area.
- Provide in-service education to all staff present on the wandering resident policy and wander guard protocol, including identification of residents at risk of wandering, the wander guard system, and the monitoring system of the lobby, secured areas, and the elevator.
- Provide in-service education to all incoming shifts of nurses, certified nursing assistants, and health and rehabilitation center staff on the wander guard system and identified target areas, including newly hired, unscheduled, and contracted staff prior to their next shift in the health and rehabilitation center.
- Assign the Administrator or Director of Nursing to be responsible for implementation of the removal plan.
- Conduct an impromptu Quality Assurance Performance Improvement committee meeting to review the facility's plan of correction and removal of immediate jeopardy, including the Medical Director.
- Inspect the wander guard system for proper function and inspect all exterior doors to ensure substantial compliance is maintained.
- Monitor and review this plan of correction through the Quality Assurance process to ensure ongoing substantial compliance is met, amending the plan of correction as needed.
- Implement the plan of correction.
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