Resident Elopement Due to Inadequate Supervision and Unsecured Door
Summary
The facility failed to provide adequate supervision to prevent a vulnerable resident from exiting the facility unnoticed and unsupervised. The resident was last observed in his room at 1:15 AM, but staff were unaware of his absence until 3:15 AM. After a search of the building and perimeter, it was determined that the resident had left the facility. The resident was found by the police approximately 12 miles away, having been off the facility grounds and unsupervised for about six to eight hours. The resident, who was cognitively intact and not identified as a wanderer or elopement risk, managed to kick open an entrance door to exit the facility. The facility's failure to ensure the entrance door was secure and to provide adequate supervision put the resident and other vulnerable residents at risk for serious harm. The incident was determined to be an Immediate Jeopardy and Substandard Quality of Care. Interviews and record reviews revealed that the facility staff were unaware of the resident's absence until a staff member entered his room at 3:15 AM. The resident was eventually located by the police, wearing appropriate clothing and carrying some belongings. The facility's policies and procedures for missing residents were initiated, but the initial failure to secure the entrance door and provide adequate supervision led to the resident's elopement.
Removal Plan
- The Certified Nursing Assistant (CNA) observed the residents' room and noted he was not present. She immediately notified the Licensed Practical Nurse (LPN) on duty. All staff on the unit began a search for the resident throughout the north unit and then moved to the south unit; at this time, all staff were directed by the LPN to conduct a search of all areas of the building and the perimeter.
- The LPN notified the Administrator in Training (AIT) that the staff searched the building and perimeter and could not locate the resident. The AIT notified the Administrator and Director of Nursing (DON) immediately after speaking with the nurse. The Administrator gave instructions to contact the Maintenance Supervisor and the Police Department. The LPN attempted to contact the resident's next of kin and the number was disconnected.
- The Maintenance Supervisor arrived at the facility. He checked all exit doors for proper functioning and noted all doors were secure. He began a search of the perimeter including outside buildings and checked all windows noting all windows were secure.
- A complete headcount was conducted by the nursing staff and all other residents were located.
- A search team was assembled by the DON and Maintenance Supervisor to search surrounding buildings, including churches, convenience stores, local bus stations and all open businesses. The LPN began making calls to all surrounding police stations. The Administrator contacted all local hospitals.
- The Officer assigned to the case arrived at the facility and completed a missing person's report.
- The Administrator notified the resident's physician to update the missing resident's status.
- The Police Department confirmed with the Administrator that the resident was safe and secure at the Police Station.
- The Director of Nursing and Social Service Director went to the Police Station, assessed the resident, found no issues or psychosocial harm then transferred the resident to the emergency room because he refused transport by ambulance. The resident was calm and expressed confidence in his purpose for leaving the facility. He stated he kicked the door, left the facility, walked to the corner of the road, caught a ride with two white ladies that helped him make a sign so he could get to (name of city) to see his family.
- The DON arrived at the hospital, gave history of incident and medical information to the Physician along with current medications and morning medications that he had not received at this time. The DON remained with the resident while the nurse obtained vital signs including a blood glucose level and body audit. No issues were noted with skin assessments, all vital signs were within normal limits and the resident stated he felt fine, but his legs were sore. The Physician ordered labs and stated they would complete medical clearance for admittance.
- A Quality Assurance Performance Improvement (QAPI) committee meeting was held regarding the incident involving Resident # 1. In attendance were the Administrator, the DON, the AIT, the Care Plan Nurse, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP), the Business Office Manager, the Maintenance Supervisor, the Wound Care Nurse, Medical Director, the Regional Nurse Consultant, the Regional Director of Operations, and the Social Services Director (SSD).
- The QAPI committee reviewed the incident, actions taken, and the policy was reviewed with no recommendations for change.
- All facility staff were 100% in-serviced regarding elopement/missing resident policies and procedures prior to returning to work by the AIT and the DON.
- One hundred percent (100%) of all residents were assessed for elopement risk by the Wound Care Nurse and DON.
- Care Plan Nurse performed a 100% audit of all resident's care plans for those identified as an elopement risk.
- DON completed a 100% audit of all residents that were identified as an elopement risk to include visual monitoring, wander guard bracelets and testing.
- 100% audit of the elopement book was performed by the Social Services Director and to ensure that all pictures were current.
- Maintenance Supervisor performed elopement drills on all shifts, this will continue for four (4) weeks and monthly thereafter and brought before the QAPI committee each month for review and recommendations. Any issues will be addressed immediately by the Administrator and DON.
- Maintenance Supervisor changed all door codes in the facility.
- AIT ordered keypad covers for all door keypads in the building.
- Maintenance Supervisor placed door alarms on all doors in the facility. The alarms will be monitored daily, and any issues will be addressed immediately by the Administrator and brought before the QAPI committee monthly for review and recommendations.
- Maintenance Supervisor contacted the alarm company to schedule testing of all doors in the building.
- State Department of Health (SA) was notified of the incident.
- The Attorney General's office (AGO) was notified of the incident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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