Failure to Follow Elopement Policy Leads to Resident Elopement
Summary
The facility failed to adhere to its Code Yellow (elopement) Policy, which resulted in a resident eloping from the facility. The resident, who had a history of mild cognitive impairment and other medical conditions, was able to leave the facility without being noticed. The facility is located near an outdoor mall and bordered by retail outlets and a major expressway, with exit doors equipped with alarm monitors. However, the alarm system was not effectively monitored, as the door alarm was canceled by staff without initiating the Code Yellow protocol. On the day of the incident, several staff members were unable to hear the door alarm due to various reasons, including being occupied with other duties or being in areas where the alarm was not audible. The receptionist, who was responsible for monitoring the security cameras, did not see the resident leave and assumed the situation was resolved when the alarm was silenced. Additionally, a CNA admitted to turning off the alarm without checking the outside area or notifying anyone, as he was in a rush to assist another resident. Interviews with staff revealed a lack of immediate response to the door alarm and a failure to conduct a head count promptly. The resident was eventually discovered missing when her lunch tray was found untouched. The facility's Code Yellow protocol, which includes conducting a head count and notifying the administrator or DON, was not followed, leading to a delay in initiating a search for the missing resident.
Removal Plan
- Facility staff immediately called a Code Yellow when facility determined that resident was missing. Staff conducted a search inside the facility including outside of facility premises.
- A Police Report was immediately filed for a missing resident, R1, to Officer (name, badge#) of the (city) Police Department.
- The CNA who responded to the alarm door was immediately educated not to turn off the alarm until a visual check/search is completed. This training was conducted by the Asst. Administrator.
- The Receptionist assigned was educated to make sure to look at the monitor to make sure no resident had exited, and not to turn off the alarm until a visual check/search is completed. Training was conducted by Assistant Administrator. The in-service included proper Alarm Response and utilization of the zone panel & camera system. Discussed appropriate times to call Code Yellow and to not cancel the alarm until given the 'all clear' following a head count. Emphasized the scope of receptionist responsibilities as the 'security station' of the facility.
- All employees were in serviced to ensure an immediate response to an exit door alarm is done, educated not to turn off the alarm until a visual check/search is completed. A head count is also to be completed to ensure that all residents are accounted for. If a resident is noted missing, staff to follow the facility protocol on missing residents. This in service will also be provided for every newly hired staff moving forward. The training was initially conducted by Social Services and Assistant Administrator for those present. The training continued both in person and over the phone for the remaining employees and was conducted by Food Services Director, CNA Supervisor, Social Services, Assistant Administrator, and Administrator. HR Manager printed out a complete facility roster which was cross-referenced to ensure all employees were educated.
- The Maintenance Director conducted an immediate check of the facility exit alarmed doors. All exit doors are alarmed and functioning. This check will continue checking daily.
- A facility wide audit to identify residents at risk for elopement, those at-risk for elopement must have photos in the elopement list posted on the bulletin board on each unit and at the reception desk for quick reference. Currently, there are 15 residents identified at risk for elopement. Audit was completed by Assistant Administrator/Social Services Director. Resident photos are taken upon admission to the facility and Elopement List is posted at each nursing station (both in a binder and on bulletin board for quick reference) and at the reception desk. Staff were in-serviced that bulletin boards will be used as the central location point in which to reference the elopement list at each nurse's station.
- The Social Service Department reassessed residents identified for elopement and elopement care plan was reviewed and updated. This was completed by Social Services.
- A facility door alarm drill was conducted to ensure staff are appropriately responding to an exit alarmed door and not to turn off the alarm until a visual check/search is completed. A facility protocol was put in place to ensure a head count is conducted after the visual check/search is done to ensure all residents are accounted for. This in-service was initiated by Social Services.
- The facility has identified approximately 25 (city) & surrounding area hospitals which facility staff continue to call daily in search of R1. This is ongoing.
- (Electric company) was called in to provide extra sound devices to project a more amplified sound to ensure staff can hear & respond to an alarm. (Electric company) will complete the work order to install necessary devices to address the concern.
- (Electric company) arrived and installed 7 new sound devices throughout the facility which project a more amplified sound to ensure staff better hear the door alarms. (Electric company) has also placed an order for dome lights to be installed at each exit door.
- All receptionists were in-serviced on Alarm Response and Utilization of Camera System to ensure camera is checked thoroughly before canceling the alarm system. Training was conducted by Assistant Administrator. The in-service included proper Alarm Response and utilization of the zone panel & camera system. Also discussed were appropriate times to call Code Yellow and to not cancel the alarm until given the 'all clear' following a head count. Lastly, we emphasized the scope of their responsibilities as representing the 'security station' of the facility.
- An additional in-service was conducted to all employees of the new amplified alarm devices to ensure staff are familiar with the amplified sound and respond immediately to the alarm. All staff were also in serviced on the purpose and locations of the zone panels should an exit alarm be sounded to determine location of alarm if uncertain. Staff were also in serviced on the location of the elopement risk residents' list that is posted on the bulletin board in every nurse's station for quick reference. Training was initiated by our two Social Services Designees and our Social Services Director for those employees who were present. The training continued both in person and over the phone for the remaining employees and was conducted by the Food Services Director, CNA Supervisor, Social Services/Assistant Administrator, Administrator and Guest Relations. The HR Manager printed out a complete facility roster which was cross-referenced to ensure that all employees were educated.
- A QA (Quality Assurance) audit tool was initiated to ensure the main exit door alarm system and the (electronic monitoring) system are checked for functionality daily and documented by maintenance. This will be done daily x14 days and 3x/week x2 weeks and weekly x 8 weeks.
- A QA audit was initiated to ensure staff are following door alarm drill, and all residents are accounted for. This audit will be done daily x7 days and 3x/week x3 weeks and weekly x 8 weeks.
- The QA audit tool that was initiated was revised after the additional amplified alarms were installed by (electric company) to ensure the exit door alarm system remains amplified. This will be conducted daily x7days, 3x/weekly x 8 weeks.
- A QA Audit was initiated to ensure receptionists are responding to an alarm system by initiating a 'Code Yellow' and checking the camera thoroughly before canceling the alarm system. This QA will be completed daily x 7 days and 3x/week x8 weeks.
- The elopement policy was reviewed and revised, which included specifying types of door alarms and defining them, as well as creating a centralized location at each nurse's station for quick reference of the elopement list. Policy was also revised to reflect the facility's specific protocols on Routine Procedure for Wandering Residents and Prevention of Missing Residents/Elopement. Training on the revised Elopement Policy was initiated by Social Services for those employees who were present. The training continued both in person and over the phone for the remaining employees and was conducted by the Food Services Director, CNA Supervisor, Social Services/Assistant Administrator, Administrator and Guest Relations. The HR Manager printed out a complete facility roster which was cross-referenced to ensure that all employees were educated.
- The QA trends will be discussed in QAPI scheduled and then monthly.
- The facility Medical Director was notified of the basis of abatement plan, and has approved.
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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