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:
Failure to Follow Fall Interventions: A resident with dementia, ESRD on dialysis, impaired mobility, and a history of falls was observed ambulating and self-transferring in her room and bathroom without staff assistance, despite orders and a care plan requiring one-person assist with a walker, call light use, frequent safety checks, and skid strips by the bed. Staff interviews confirmed the resident was transferring independently and that the skid strips were not in place as documented.
A resident assessed as high risk for falls did not receive the physician-ordered fall mat on the right side of the bed. Surveyors observed no mat during multiple checks, and the TAR did not reflect the intervention. The resident said the mat had been removed after a new bed was placed, while an RN and the DON acknowledged the order remained in place even though the mat was no longer being used.
Smoking safety interventions were not consistently implemented for four residents who smoked. Two residents were observed smoking with staff supervision but without the smoking aprons listed in their assessments and care plans, and two other residents were also observed smoking in wheelchairs without aprons despite care plan interventions requiring them. The DON confirmed the apron requirement for two of the residents, while the ADON stated residents sometimes complained about the aprons and that he did not know when smoking assessments were completed.
A resident with cerebral palsy, severe cognitive impairment, wheelchair use, and a care plan requiring a mechanical lift for all transfers was manually transferred by a CNA instead of using the lift. During observation, the CNA lifted the resident by the upper back and moved him between the wheelchair and bed without mechanical assistance, despite having completed lift competency training and despite the DON confirming the resident required a mechanical lift for all transfers.
Failure to supervise a resident at risk for elopement led to repeated exit-seeking and wandering events, including being found off the unit and near exterior areas. The resident had dementia with cognitive impairment, hemiplegia, and diabetes, and staff notes described missing documentation of several wandering episodes, an incomplete care plan intervention, and incidents involving a broken alarmed door, a Wanderguard, and an unknown visitor letting the resident off the unit.
A resident with severe cognitive impairment fell during a lift transfer when a sling strap came loose and the chest strap clip broke, and two other residents were observed being transferred with total body lifts using slings that were not verified against their care plans or mobility assessments. Staff interviews showed some CNAs relied on the sling already in the room or on how it fit, rather than consistently checking the care plan or Kardex for the correct sling size and transfer method.
Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure that a resident's fall interventions were in place for one resident reviewed for falls. The resident had diagnoses of dementia and end-stage renal disease requiring dialysis, was documented as having intact cognition but needing supervision with ADLs, transfers, and walker use, and was identified as a fall risk due to ESRD, impulsive behavior, and impaired mobility. The resident's nursing and provider orders directed staff to assist with ambulation, remind the resident to use the call light and wait for staff, and complete frequent safety checks each shift. The resident had a documented fall in which she was found sitting on the floor between her drawer and walker with bleeding from a forehead injury and a skin tear to her jaw, and she was transferred to the hospital where she received stitches. The incident report stated the resident lost her balance when she walked to her drawer to close it. The resident's care plan later identified a self-care performance deficit related to actual falls, weakness, and impaired mobility, and included interventions such as assistance from one staff member with a walker and gait belt, assistance with transfers and toileting, use of assistive devices, skid strips next to the bed, and frequent monitoring for safety. During observations, the resident was seen ambulating and self-transferring in her room and bathroom without staff assistance and at times without using her walker or call light. Staff observed the resident walking independently in her room, and an unidentified staff member passed by without entering the room. The resident stated that she walked and used the bathroom by herself and did not need to follow instructions. Staff interviews confirmed that the resident transferred independently and ambulated without a walker or staff assistance, while another nurse stated the resident was not supposed to self-transfer and that skid strips were not present despite being listed in the care plan. The DON stated that staff were expected to follow resident orders and care plans for safety.
Missing Ordered Fall Mat for High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a resident assessed as high risk for falls received the physician-ordered fall prevention intervention of a fall mat positioned on the right side of the bed. Resident #50 was admitted with diagnoses including orthostatic hypotension, lack of coordination, reduced mobility, and communication deficit. The resident’s fall risk assessment showed a score of 50, indicating high risk for falling, and the care plan identified the resident as at risk for falls and fall-related injury due to a history of falls with fracture, cognitive impairment, and decreased safety awareness. During multiple observations, the resident was seen at the bedside and no fall mat was present on the right side of the bed or located in the room. The physician order dated 6/7/2026 specified a mat on the right side of the bed, but the MAR and TAR did not reflect the fall mat as an implemented intervention. The resident stated the fall mat had been removed after a new bed was placed and had been gone for a long time. An RN stated the resident was a fall risk and that the order for the fall mat should be followed or cancelled if no longer needed. The DON stated the bed had been changed out and the mat would get in the way, and the order should have been cancelled.
Smoking Safety Interventions Not Followed
Penalty
Summary
The facility failed to ensure adequate assessment and implementation of smoking safety interventions for four sampled residents who smoked. Residents #12 and #85 were observed smoking in the designated smoking area with staff supervision on multiple occasions, but neither was observed wearing a smoking apron even though the smoking binder and care plan indicated they needed one. During an interview, the ADON confirmed both residents were listed as needing aprons and stated the residents sometimes complained about the apron, but they should not smoke unless they put it on. The ADON also stated he does not go out with smokers often and does not know when assessments are completed. Resident #12 had diagnoses including COPD, muscle weakness, and epilepsy, and smoking evaluations noted tobacco use and balance problems while sitting or standing; smoking was added to the care plan with a clothing protector intervention. Resident #85 had diagnoses including hemiplegia and right-hand contracture, and although initial smoking evaluations indicated tobacco use with no impairments, smoking was later added to the care plan with a clothing protection requirement. Resident #52, who had CVA with right-sided weakness and paralysis, diabetes, mood disorder, major depressive disorder, and right hand and upper arm contracture, was observed smoking in a wheelchair without a smoking apron despite a care plan intervention requiring one. Resident #11, who had TBI, schizoaffective disorder, major depressive disorder, paraplegia, and upper extremity contractures, was also observed in the smoking area in a wheelchair without a smoking apron, and no attempt was made by the smoking monitor to get the apron on. The DON confirmed that Residents #52 and #11 were supposed to wear smoking aprons when smoking, and the facility smoking policy required residents to be educated and evaluated for smoking upon admission, re-admission, and quarterly.
Failure to Use Required Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to ensure Resident #5 was transferred with a mechanical lift as required. Resident #5 was admitted with diagnoses including cerebral palsy, BPH, and hypertension, and a quarterly MDS showed severe impairment in thinking with a BIMS score of 4. He required substantial to maximal assistance with toileting hygiene, used a wheelchair for mobility, and his care plan documented a history of falls with interventions initiated for a mechanical lift for all transfers to wheelchairs. A POC task also indicated he required a mechanical lift for transfers every shift, and he was listed among residents requiring a sling/mechanical lift. During observation, CNA C provided incontinent care and transferred Resident #5 from his specialized wheelchair to the bed and back without using a mechanical lift. Instead, she manually lifted him by placing her arms around his upper back and interlocking her fingers. In interview, CNA C stated she had been employed for a month, had completed lift competency during orientation, but did not use the lift because she felt comfortable transferring him without assistance and had never used the mechanical lift on him, although other staff did. The DON stated Resident #5 required a mechanical lift for all transfers and that staff could see this in the POC. The facility policy stated mechanical lifting devices shall be used for lifting and moving residents when necessary.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident elopement for a resident who was identified as at risk for elopement and did not reside on a secured unit. The resident had diagnoses including hemiplegia, diabetes, and dementia, and the MDS indicated cognitive impairment. The record showed multiple elopement evaluations with changing results, including several assessments that identified the resident as at risk for elopement in July 2026, while earlier assessments had indicated not at risk or were incomplete. The care plan identified the resident as an elopement risk/wanderer related to impaired safety awareness, but the record contained only one incomplete intervention related to wandering, and no resident preferences were included. Behavior monitoring documented exit-seeking and wandering behaviors on multiple occasions in May, June, and July 2026, but progress notes did not document the behaviors noted on 5/21/26, 6/21/26, and 7/14/26. A physician order for a Wanderguard was created after the resident was found wandering outside on the curb, and staff notes described discussions with family and assessments after the resident was returned to the unit. The resident was later involved in additional elopement-related events. Staff statements and progress notes described the resident being found near a door, in the front hall, in the assisted living area, and off the unit near common areas, with staff searching for her after she was reported missing. One note stated the resident could escape through a security door because the alarm was broken and had not been fixed yet. Another investigation note stated the resident was found off the unit in a common area adjacent to the unit after being let off by an unknown visitor. The facility determined that the resident was cognitively unable to recognize the door requiring a code and would be physically unable to open it without assistance. The report states the facility was out of compliance with resident safety and supervision since 4/12/26.
Failure to verify correct sling size and safe lift use during resident transfers
Penalty
Summary
The facility failed to ensure staff followed accident prevention interventions and safe device use for three sampled residents who required total body lift transfers. The report states that four certified nursing assistants did not verify the correct sling size before transferring residents, despite care plans and the lift’s sling-size identification system directing staff to use specific sling sizes based on resident weight and transfer needs. Resident 39 had severe cognitive impairment, Alzheimer’s disease, dementia with behavioral disturbance, anxiety disorder, and muscle weakness. Her care plan and mobility assessments showed a progression from sit-to-stand lift use to total body lift use with two staff members and a medium sling. On 5/1/26, she was transferred from her wheelchair to her bed by a CNA using a sit-to-stand lift when the sling strap came loose from the hook on the lift and the chest strap clip broke, causing her to fall backward onto the floor. She sustained a skin tear on her right forearm, bruising to the right side of her face, redness to the right side of her body, and a bruise on her right frontal scalp. She was sent to the ER, where X-rays showed no acute findings or fractures. Observations later showed resident 39 being transferred with a total body lift using a large sling, and resident 8 and resident 25 were also observed with large total body lift slings on. Resident 8 had paraplegia, moderate cognitive impairment, and a care plan directing total body lift transfers with a medium and extra-large sling, while his mobility assessment indicated an extra-large sling and two staff members. Resident 25 had vascular dementia and muscle weakness; her care plan directed total body lift transfers with two staff members, and her mobility assessment indicated a large sling. Interviews with CNAs showed that staff sometimes relied on the sling already in the room or judged sling size by how it fit, rather than consistently referring to the care plan or Kardex. The DON and MDS coordinator stated that staff were expected to use the resident’s care plan or Kardex to determine sling size for safe transfers.
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