Elopement Incident Involving Resident with Schizoaffective Disorder and Vascular Dementia
Summary
The deficiency reported in the survey pertains to the failure of a long-term care facility to provide adequate monitoring, supervision, and response to prevent the elopement of a resident identified as an elopement risk. The resident in question, identified as R901, had diagnoses including Schizoaffective Disorder-Bipolar Type, Anxiety Disorder, Violent Behavior, and Vascular Dementia. Despite being considered at risk for elopement and wearing a Wanderguard ankle bracelet, R901 managed to leave the facility undetected on the evening of 03/25/24. Staff only became aware of the elopement approximately eight hours later, leading to a significant delay in locating the resident. The facility's records indicated that R901's care plan included interventions such as redirecting the resident when wandering or exit-seeking and the use of a Wanderguard ankle bracelet. However, despite these measures, R901 was able to exit the facility without staff awareness. Interviews with staff members revealed discrepancies in their recollection of events, with some not recalling hearing any door alarms on the evening of the elopement. Surveillance footage from a nearby business indicated that R901 had been outside the facility for several hours before staff realized they were missing.
Penalty
Resources
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Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
A resident with diabetes, orthostatic hypotension, impaired mobility, and severely impaired cognition (BIMS 5/15) fell from bed to floor while a CNA was providing incontinence care. The resident had a history of intolerance to sitting up, low BP episodes, and resistance to sitting at the edge of the bed, but resistance to care was not included in the care plan. During the incident, the resident resisted care, tried to get out of bed, and slid to the floor, requiring two staff to return her to bed. The DON later stated the CNA should have stopped care when resistance occurred, reminded the resident she needed assistance to get out of bed, ensured safety, and then reapproached, indicating that adequate supervision and assistance were not provided to prevent the fall.
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.
Staff failed to enforce the facility’s smoking and vaping policy by allowing multiple residents to keep vapes and, in at least one case, marijuana in their rooms, rather than securing these items in locked areas as required. Residents with intact cognition and significant medical conditions, including hemiplegia, CKD, cervical spine injury, diabetes with neuropathy, Alzheimer’s disease, and chronic pain, reported possessing and independently charging vapes in their rooms. Staff across disciplines, including CNAs, LPNs, housekeeping, and the SW, repeatedly noticed or were told about marijuana odors and resident vape use, particularly around certain rooms, but these observations were not consistently reported or documented, and care plans and safe smoking assessments often did not reflect actual vape or THC use.
A dependent, cognitively impaired resident with dementia, depression, and muscle weakness, coded as requiring total assistance for rolling in bed, fell from bed during ADL care when a CNA turned away to rinse a washcloth. At the time of the fall, the bed was not lowered and ordered floor mats were not in place. Staff later documented progressive swelling, bruising, and pain in both lower legs and ankles, and imaging ultimately showed acute fractures of the distal tibia and fibula. Interviews with an LPN, MDS nurse, Rehab Manager, and DON confirmed that the resident was totally dependent, would not follow commands, and should have been safely positioned in the middle of the bed before the CNA turned away, indicating inadequate supervision and failure to follow fall‑prevention measures.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Provide Adequate Supervision During Incontinence Care Resulting in Fall
Penalty
Summary
Facility staff failed to provide adequate assistance and supervision during incontinence care to prevent a fall for one resident. The resident had diagnoses including diabetes, high blood pressure with episodes of orthostatic hypotension, and impaired mobility and self-care related to lumbar spine fusion. An admission MDS with an ARD of 1/6/26 documented a BIMS score of 5/15, indicating severely impaired cognitive abilities for daily decision-making. According to the Rehab Director, the resident was unable to tolerate therapy, was resistant to sitting up on the side of the bed or in a wheelchair, had episodes of low blood pressure, reported feeling ill while sitting up, and would vomit. Prior to the fall on 3/6/26, the resident’s care plan did not include a problem related to resistance to care. On 3/6/26 at 4:30 AM, while a CNA was providing incontinence care, the resident experienced a witnessed fall from the bed to the floor. Nurse’s notes documented that the resident was resisting care, attempted to get out of bed, and slid off the bed to the floor, requiring two staff members to assist her back into bed. The DON later stated that, in this situation, the CNA should have stopped care when the resident became resistant, reminded the resident that she required assistance to get out of bed, ensured the resident was safe, and then reapproached the resident. Family Member #1 reported observing staff working to transfer the resident back to bed after the fall. These findings show that staff did not provide adequate supervision and assistance during incontinence care to prevent the fall.
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.
Unsecured Vapes and Illicit Substances in Resident Rooms
Penalty
Summary
Facility staff failed to ensure that electronic cigarettes (vapes) and illicit substances were securely stored and controlled, contrary to the written smoking policy prohibiting smoking/vaping inside the facility and prohibiting residents from keeping smoking paraphernalia in their possession. The policy required all such items to be kept at the nurse’s station, in the med room, or another locked safe area. Despite this, multiple residents reported having vapes in their rooms and charging them independently, and staff interviews and documentation showed a pattern of noncompliance with the smoking policy and lack of secure storage of these items. One resident with hemiplegia, generalized muscle weakness, chronic kidney disease, and intact cognition was care planned as an active smoker with a history of noncompliance and prior loss of smoking privileges. The care plan included an intervention to ensure smoking items were stored correctly per policy, but the resident reported that he vaped, kept his vape in his room, and charged it without staff assistance. The social worker reported having taken multiple marijuana and nicotine vapes from this resident’s room in the past, most recently a few months before the survey, with the items found in plain sight. The resident’s safe smoking assessment did not address vape use, and staff interviews showed that, although the activities department stated vapes were to be locked and only used at designated smoking times, they had only “heard” that residents had vapes and had not observed them. Another resident with a history including cervical vertebrae dislocation, chronic pain syndrome, generalized muscle weakness, and intact cognition was care planned for a history of smoking with a goal not to smoke without supervision, but the safe smoking assessment listed the resident as a non-smoker. This resident stated he had a vape in a tote bag on his bed, that staff allowed him to vape while in bed, and that he charged the vape himself using his phone charger. A third resident, with diabetes, neuropathy, need for continuous supervision, and intact cognition, was care planned as a smoker with a history of noncompliance and documented vape use. A surveyor noted an odor resembling marijuana from this resident’s room after another resident entered and closed the door; the administrator also noted the odor, and later the resident admitted to having marijuana in his room and turned over a small baggie and a lighter. Multiple staff, including LPNs, CNAs, housekeepers, and a unit manager, reported smelling marijuana in or near this resident’s room over time, but the social worker, who stated she had received such reports and requested room searches, had not documented these conversations, and the clinical record contained no documentation of these reports or requests. A fourth resident with Alzheimer’s disease, major depressive disorder, generalized arthritis, generalized muscle weakness, and intact cognition was documented in a physician progress note as reporting THC vape use for pain management. The resident’s care plan did not address smoking status, and the safe smoking assessment listed the resident as a non-smoker. This resident stated she did not smoke cigarettes but had a vape in her room and could charge it without staff assistance. Staff interviews indicated that CNA and housekeeping staff had noticed marijuana odors in the hallway and specifically from the vicinity of this resident’s room, but some staff did not report these odors because they were unsure of the source. The physician later stated he knew the resident used THC for pain control but had no knowledge that she was using it in the facility. Across these residents, the facility’s own policy requiring secure storage of vapes and smoking materials and prohibiting unauthorized controlled substances was not implemented, and staff reports and observations of marijuana odors and resident possession of vapes were not consistently documented or acted upon in a manner that ensured secure storage and prevention of misuse or hazards.
Failure to Provide Adequate Supervision During Bedside ADL Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a hazard‑free environment during ADL care for one dependent resident, resulting in a fall with fractures. The resident had diagnoses including unspecified dementia without behavioral disturbance, major depressive disorder, and muscle weakness, and was coded on the MDS as dependent for rolling left and right in bed, meaning the helper did all of the effort. The resident was also coded as rarely/never understood, so no BIMS was completed. Facility orders included the use of floor mats to the side of the bed while the resident was in bed for safety related to frequent falls. On the date of the incident, a CNA was providing ADL care to the resident while the resident was in bed. According to nursing documentation and staff interviews, the CNA turned her back to rinse a washcloth, during which time the resident rolled out of the bed onto the floor. LPN interview and nursing notes indicated that the bed had not been lowered and fall mats were not in use at the time of the fall, despite existing orders for floor mats. Staff, including the MDS nurse, Rehabilitation Manager, and DON, stated that the resident was totally dependent for ADLs, would not follow commands, and that the CNA should have ensured the resident was safely positioned in the middle of the bed before turning away. Following the fall, nursing documentation described that the resident was assessed and initially noted to have a small skin issue on the left lower arm, with no immediate signs of distress or pain. Over the next several days, nurses documented bilateral lower leg and ankle swelling, bruising, and obvious pain during ADL care. X‑rays of the bilateral ankles and feet were ordered and performed, and radiology results later identified acute‑appearing fractures of the distal tibia and fibula with posterior and medial angulation, as well as a fibular fracture. The resident was subsequently sent to the hospital and was reported to be admitted with bilateral tibial fractures. The facility’s own fall prevention and management policy referenced assessing fall risk factors including the resident’s current ADL status, but the actions taken during the ADL care did not prevent the fall for this dependent resident.
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