Failure to Prevent Resident Elopement
Summary
The facility failed to provide adequate supervision to prevent a resident, identified as an elopement and wandering risk with moderate cognitive impairment, from exiting the facility unnoticed and unsupervised. The resident was observed by a therapy staff member in the lobby at approximately 12:00 PM and was later found near the side of the main road, approximately 100 feet from the facility grounds, at 12:08 PM. Facility staff were unaware that the resident had exited the facility, and the resident was retrieved by a CNA after being informed by the therapy staff member. The resident had been exhibiting exiting behavior earlier that day and was redirected. Despite wearing a wander guard device, the resident managed to leave the facility. The facility's investigation revealed that the door alarms and wander guard devices were functioning properly when tested, but there was radio static interference that could have caused the failure. The resident was found sitting on a cement slab near the main roadway, dressed appropriately for the weather, and was assessed to have no physical injuries or psychosocial harm upon return to the facility. Interviews with staff confirmed the sequence of events and the location where the resident was found. The facility's maintenance director routinely checked the exit doors and wander guard devices, and the door alarm vendor identified radio static interference as a potential issue. The facility's failure to provide adequate supervision and ensure the proper functioning of the wander guard system resulted in the resident's elopement, posing a significant risk to the resident's safety and well-being.
Removal Plan
- The Administrator and Director of Nurses were notified of an immediate jeopardy for failure to provide supervision to prevent an elopement for Resident #1 who was identified as an elopement and wandering risk.
- Resident #1 was retrieved and re-entered the building, she was immediately assessed by the Director of Nurses. A body audit was completed with no injury noted. Resident was interviewed by the Director of Nurses. The Director of Nurses verified that her wander guard was properly placed and functioning.
- Resident #1 was immediately placed on alert charting by the Director of Nurses to identify location every hour.
- The Director of Nurses immediately notified the Administrator of the elopement. The Director of Nurses then notified the responsible party of the resident and the Medical Director. The Administrator notified the Maintenance Director.
- The Administrator notified the State Agency.
- The Administrator notified the Attorney General.
- All residents were checked and accounted for in the building by the Certified Nursing Assistants and reported to the Administrator. Staff was interviewed by the Director of Nurses and the Administrator to determine if any resident was exit seeking that had not already been identified. None were identified.
- The Director of Nurses and Administrator began investigation and collection of statements from all staff present.
- All residents with wander guards were checked for proper placement and function by the Licensed Practical Nurse Supervisor. All were found to be properly placed and functioning.
- All exit doors and alarms were checked for proper functioning by the Maintenance Technician.
- Vendor, the door alarm provider, was called by the Maintenance Director to schedule an onsite visit.
- The Administrator began a door monitoring schedule until Vendor could conduct an on-site visit.
- The notice to visitors on the door was revised by the Administrator to be bigger and brighter instructing to not let any resident out of the door without notifying staff.
- Administrator began inservicing all staff on the Missing Resident policy and the Safe Guarding the Wandering Resident policy. Staff to be inserviced before returning to work.
- The plan of care of Resident #1 was updated to reflect the elopement by the Registered Nurse.
- All tasks in the electronic healthcare record of residents with wander guards were updated by the Licensed Practical Nurse Supervisor to include the task of the Certified Nursing Assistant to check the proper placement of the wander guard every shift. The Certified Nursing Assistants began to be inserviced on this by the Licensed Practical Nurse Supervisor. Staff to be inserviced before returning to work.
- The Elopement Risk Evaluation began being updated on all residents by the nurse supervisors. No new residents with risk of elopement were identified.
- The Elopement Risk Binder was created for all residents with wander guards to include their picture, name, date of birth and medical record number by the Licensed Practical Nurse Supervisor. The staff was inserviced on these binders and their location at each nurse desk. Staff to be inserviced before returning to work.
- All nurses were inserviced and completed a competency check-off on how to test a transmitter (wander guard) every shift as indicated on the Medication Administration Record by the Licensed Practical Nurse Supervisor. Staff to be inserviced before returning to work.
- Daily Stand Up Agenda in which all staff attends on two shifts was updated by the Administrator to include identifying what residents have wander guards. Note that the agenda previously included to identify any doors/alarms not working properly and any elder who is at risk for elopement.
- Vendor serviced the door and installed keypads in which the door remains locked. A code is required in order to enter and exit the door.
- Quality Assurance and Performance Improvement committee met that included the Administrator, Director of Nurses, Medical Director, RN Consultants, Infection Preventionist, Licensed Practical Nurse Supervisor, Maintenance Director, President/Co-Owner, and Chief Operating Officer to discuss the elopement of Resident #1 and updating the plan of care. Reviewed the Missing Resident policy. No recommendations for changes were made.
- Quality Assurance and Performance Improvement committee met again to include Administrator, Director of Nurses, RN Consultant, Nurse Practitioner, Social Service Director, Licensed Practical Nurse Supervisor, Maintenance Director, Activities Director, Admissions Coordinator, Administrative Assistant, and Infection Preventionist as a follow up to ensure all interventions that were put in place were effective. No concerns were noted. All findings will be discussed at the monthly Quality Assessment and Assurance meeting for a minimum of three months or until the compliance is maintained.
- The Elopement Risk Evaluation is to be completed by the Registered Nurse Supervisor on all new residents upon admission and quarterly thereafter.
- Visual checks to be initiated for all residents by the medication cart nurse for the first 72 hours upon admission and a wander guard to be placed if deemed necessary.
- Missing Resident and Safeguarding the Wandering Resident policies continue to be inserviced upon hire and quarterly thereafter.
- Monitoring to be completed as follows: Elopement Drill to continue to be completed quarterly. The wander guard audit will continue to be completed monthly by Licensed Practical Nurse supervisor. Maintenance Director/Housekeeping to continue with daily door checks twice a day. Wander guard proper placement and functioning to be checked every shift on the Medication Administration Record.
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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