Failure to Prevent Elopement and Ensure Safety Measures
Summary
The facility failed to prevent the elopement of a cognitively impaired resident with a history of attempted elopement. The resident, who was assessed to be at risk for elopement, left the facility through an alarmed elevator that did not sound an alarm. The resident was found 1.4 miles away from the facility by a tenant at a previous residence. The facility's failure to ensure the proper functioning of the alarm system and the lack of staff awareness led to the resident's unsupervised departure and subsequent discovery far from the facility. Additionally, the facility did not ensure that other residents at risk for elopement had functioning electronic monitoring bracelets. One resident was observed without an electronic monitoring bracelet despite a physician's order, and another resident had a bracelet that did not function properly due to being expired. The facility's failure to maintain and check the functionality of these monitoring devices put residents at risk for elopement. The facility also failed to implement appropriate fall interventions for two cognitively impaired residents who were assessed to be at risk for falls. The care plans for these residents did not have the necessary fall interventions in place, further indicating a lack of adequate supervision and preventive measures. These deficiencies affected multiple residents and highlighted significant lapses in the facility's safety protocols and monitoring systems.
Removal Plan
- A resident head count was completed by facility staff to ensure that all current residents were accounted for. All residents were accounted for.
- Resident #70 was returned by the Police department and daughter.
- Resident #70 had a head-to-toe assessment completed by Licensed Practical Nurse (LPN) #672, including visual assessment and physical assessment, and including but not limited to heat related issues. All results were unremarkable for significant negative effects.
- Assessments were completed on residents at risk for elopement by DON and Licensed Practical Nurse (LPN) #615. At risk residents were determined by the most recently completed wander assessment.
- Resident #70 was immediately placed on a 1:1 supervision by State tested Nursing Assistant (STNA) #678 upon return to the facility, at which point the one on one was discontinued by the DON and STNA #678 was reassigned at the elevator to ensure safety for all residents at risk for wandering.
- The facility implemented a plan for a designated staff member to remain in place at elevator door 24 hours/7 days per week, to ensure residents at risk of wandering did not exit. This would remain in place until root cause of functioning concern is identified and corrected.
- Resident #70's physician was notified of Resident #70's return to the facility and assessment findings by ADON #343.
- All staff members present were interviewed by ADON #343.
- All stairwell and exit door alarms were checked for functioning by DON. The facility indicated there were no concerns noted.
- All residents with an order for a monitoring device (wander guards bracelets) were assessed to ensure placement of the wander guard and proper functioning of wander guard by DON and ADON #343.
- The facility indicated any wander guard that was not functioning properly was replaced by DON/designee.
- Resident #70's previous wander guard was removed, and a new wander guard was placed on Resident #70 by the DON.
- Elopement drills for staff were conducted by the DON.
- An elopement drill was conducted for all staff by DON.
- An elopement drill for all staff was conducted by Registered Nurse (RN) #563.
- All staff in-service related to elopement protocols began by the DON and/or designee, including but not limited to ensuring that wander guards are in place and functioning as ordered, how to engage wander guard bracelets prior to applying, how to check for functioning of the wander guard bracelet and wander guard system, wandering residents' policy, elopement policy, pictures to be obtained and uploaded to EHR upon admission to the facility, the elopement binder, and notification protocols by the Administrative Team. No staff who are absent or PRN (pro re nata) is permitted to return to the floor and resident care until this in-servicing /education is completed.
- All nursing staff in service on correct input of wander guard orders by the DON and/or designee (check placement and check function every shift) upon placement of wander guard by DON/designee. No staff who are absent or PRN (pro re nata) is permitted to return to the floor and resident care until this in-servicing /education is completed.
- All nursing staff was to begin ensuring an order is in place to check wander guard placement and function every shift daily, ongoing.
- All wandering device orders were to be transcribed into point click care (PCC) the day of implementation by nursing audit began by the DON/designee daily for 2 weeks then weekly at RISK for 3 month and present to Quality Assurance Performance Improvement (QAPI).
- The profile pictures of all residents at risk for wandering were audited for accurate profile pictures in the electronic health record (EHR) by Medical Records/Central Supply #524. DON /designee began to audit profile pictures for all new admissions, five residents a week for two weeks then weekly for three months. Results would be presented to the facility Quality Assessment and Performance Improvement (QAPI).
- Resident #70's profile picture was uploaded to the EHR and was placed in the wander guard book by Medical Records/Central Supply #524.
- The elopement binder was audited for accuracy by Medical Records/Central Supply #524. No other discrepancies were identified. The elopement binder is to be audited for accuracy by DON/ designee five times a week for 2 weeks then weekly for 3 months. Results will be presented to QAPI.
- The DON and Administrator met with Alta Contractor (electronic monitoring company) regarding wander guard alert system to ensure the system was functioning per manufacturer's guidelines. No concerns were identified.
- All residents with wander guard bracelet orders were clarified to ensure an order to check placement and check function is placed in the HER and care planned by DON and LPN Supervisor #455.
- Wandering risk assessments were completed on all census active residents by DON and LPN Supervisor #455. All residents identified at risk for wandering were given a wander guard placed on their person, an order written for wander guard and the Provider/resident representative was notified. Additionally, the care plan was updated.
- Resident #14 was identified to be at risk of wandering. Her physician was notified, and an order was given for a wander guard. A wander guard was placed on her, checked for placement/function, and her care plan was updated by Registered Nurse (RN) #443.
- All new employees hired by the facility would receive education on residents at risk for wandering policy by the DON /designee.
- The Minimum Data Set (MDS) nurse was educated by the DON, on ensuring that all residents who have an order for wander guard have a care plan in place for the wander guard. The education included ensuring that an intervention for checking the function and checking the placement of the wander guard are in the plan of care by DON/designee.
- All staffing agencies utilized by the facility were provided education for their employees by the DON and a copy of this training was placed in the agency education binder by the Administrator.
- All activities department and front desk staff were in serviced on PCC profile picture uploading upon admission by Administrator/ designee. Staff who were absent or PRN (pro re nata) would not be permitted to return to the floor and resident care until this in-servicing /education was completed.
- All receptionists were in service on the elopement binder review and updating the binder weekly and with any new admission by the Administrative Team. Staff who were absent or PRN (pro re nata) would not be permitted to return to the floor and resident care until this in-servicing /education was completed.
- The Admissions Director was in serviced on posting new admissions room number and expected date of admission by time clock daily (which is a secured area), by Administrator/designee. No staff who are absent or PRN (pro re nata) is permitted to return to the floor and resident care until this in-servicing /education is completed.
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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