Resident Elopement Due to Inadequate Supervision
Summary
The facility failed to provide appropriate supervision for a resident, identified as R78, which resulted in the resident successfully eloping from the facility. R78 was admitted with diagnoses including dementia, cognitive communication deficit, and abnormalities of gait and mobility. The resident's Quarterly Minimum Data Set (MDS) indicated moderate impairment in cognitive skills for daily decision-making, but no behaviors of rejection of care or wandering were noted. On the day of the incident, R78 was found outside the facility by a dietary staff member, wet from the rain, and lying on the ground near a tree. Interviews with facility staff revealed that the door alarm had sounded, but the receptionist was unable to respond immediately due to assisting a family member. The alarm stopped after about 15 seconds, and a CNA later noticed R78 was missing from her room. The CNA and other staff searched the building but could not find R78 inside. The Director of Nursing (DON) and the Administrator both stated that R78 was not considered an elopement risk prior to the incident, and an updated assessment had not been conducted until after the elopement occurred. The facility's policy on elopements and wandering residents emphasized that alarms are not a replacement for necessary supervision and that residents should be assessed for elopement risk upon admission and throughout their stay. However, the facility did not conduct an updated assessment for R78, who was found to be walking the halls but had not previously attempted to elope. The lack of timely response to the door alarm and the absence of an updated risk assessment contributed to the resident's ability to leave the facility unsupervised.
Removal Plan
- Resident #78 was returned to the facility and experienced no injury while outside of the facility. The Director of Nursing completed the initial report to South Carolina Department of Public Health for the elopement of Resident #78.
- When Resident #78 returned to the facility an Elopement Assessment, Head to Toe Skin Assessment and an Incident Report were completed by the charge nurse including notification to the Physician and Responsible Party/Family of the incident and safe return.
- Facility nursing staff initiated q 15-minute checks x 72 hours on Resident #78. Checks were completed without any negative occurrences.
- Based upon the elopement assessment, a wander guard bracelet was placed on Resident #78 by the charge nurse with the Attending Physician and Family notified by the charge nurse. Resident #78's CP has been updated with intervention for wander guard by MDS.
- Resident #78's Care Plan was updated to reflect this incident and her increased exit seeking behavior by the MDS Director.
- The Administrator completed a post incident Brief interview Mental Status on Resident #78.
- Nursing Supervisor accounted for all residents listed on 24-hour census. All residents were accounted.
- Nursing Supervisor checked all residents with wander guard bracelet. All doors with wander guard alarms were audited by Maintenance Director or designee determined to be in good working order.
- Wander guard door in the EAST building will be monitored by staff to ensure residents at risk do not elope from the buildings.
- Administrator provided education to the Central Supply Clerk, DON and Unit Managers on a Par System for Wander guard Bracelets.
- Administrator provided education to the Central Supply Clerk regarding the maintaining adequate supply of Wanderguard bracelets. PAR level was established of at least 5 and she was educated and verbalized understanding. She placed an order for 20 wander guards to meet current needs and exceed PAR Level.
- The DON completed an Audit of residents identified as an elopement risk and needing a WanderGuard Bracelet. The DON created log to track which resident was issued a wander guard bracelet and the expiration of date of the Bracelet. The DON will update the log as wander guard bracelets are issued or as they expire. New wandering and elopement assessments will be completed by the DON, IDT Team and charge nurse on all residents and care plans will be updated as needed.
- The Elopement Policy has been reviewed by the DON, Administrator and Corporate Nurse Consultant to include supervision for residents with increased behaviors/exit seeking behaviors.
- Door Vendor assessed wander guard doors and in the assessment process the vendor caused disruption of normal working and was not able to restore normal operations. Doors were already being watched by staff post elopement.
- A second vendor was able to assist Maintenance Director in replacing equipment that had been damaged and doors returned to normal operations. Door watch continues pending abatement of IJ.
- Wander guard bracelets were received by Central Supply Clerk and nurses place bracelets on newly identified residents determined to be at risk and the bracelet removed by the resident and the bracelet found not to be operating by nursing staff.
- Staff will be educated on the elopement policy to include management of exit seeking behaviors. Any staff member who has not completed training will not be allowed to work until training is complete.
- The training is conducted by the DON, Staff Development Coordinator and the Administrator.
- Staff will be educated on the elopement policy and how to manage exit seeking behaviors upon hire, annually and as needed by the Staff Development Coordinator, Administrator, Director of Nursing or Designee ongoing.
- Elopement drills will be conducted weekly for 4 weeks on each shift by the Maintenance Director or Designee.
- Monthly elopement drills will be done for two months and then at least quarterly by the Maintenance Director or Designee.
- The corporate regulatory consultant will do monthly random audits of behavior care plans and assessments for 90 days.
- The DON/Designee will audit binder monthly and alert the central supply clerk of the number of bracelets to expire in order to ensure PAR is maintained.
- An Ad Hoc QAPI Committee Meeting was held with the DON, Administrator and Medical Director. The plan of actions taken were reviewed and it was determined that all necessary actions had been taken.
- The results of the audits, drills and wander guard documentation will be reported to the QAPI Committee for review and assessment to assure continued compliance.
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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