Resident Elopes Due to Faulty Door and Lack of Supervision
Summary
The facility failed to ensure adequate supervision and safety measures for a resident identified with confusion, poor safety awareness, and a desire to exit the facility. This resident, who had multiple medical conditions including moderate cognitive impairment, was able to elope from the facility through a door that was not in good repair and had a non-functioning alarm system. The door, located on the ground floor leading to a courtyard and main street, was found to be ajar and the alarm did not sound, allowing the resident to leave unnoticed by staff. The resident was found by a bystander on a sidewalk near a busy intersection, approximately 183 feet from the facility entrance, during the early hours of the morning. The resident was wet, without shoes, and wearing only pajamas and socks in cold and rainy weather. The resident sustained injuries from a fall during the elopement and was subsequently taken to a hospital where they were diagnosed with cold exposure and a head injury. Interviews with staff revealed that the door had been in disrepair for some time, with no alarm sounding when opened, and was frequently used by residents and staff to smoke. Staff were unaware of the resident's exit due to the lack of a functioning alarm and supervision. The facility's policy on elopement was found to be lacking in preventative measures and monitoring processes, contributing to the resident's ability to leave the facility undetected.
Removal Plan
- R1 was re-assessed for Elopement risk to complete accurate assessment.
- R1's care plan was reviewed and updated to include: R1 placed on monitoring while out of resident's room; R1 placed on hourly monitoring. There will be a sign off sheet to reflect his behavior, what he is doing, how is acting if he is verbalizing wanting to leave while his family is not in the facility. Wife is in the facility daily. R1's wife was educated to share with the staff to alert the staff when leaving.
- Facility initiated in-service on R1's direct care staff on plan of care to address elopement risk and precautions. This will continue until all direct care staff for R1 have been provided with in-service. The staff will not be allowed to work the shift without being In-serviced prior. Facility Scheduler, Nurse Supervisor, Administrator, and/or Designee will check if in-services are all completed prior to beginning of the shift.
- All residents in the facility who have cognitive impairments have scored moderate BIMS and are at risk high risk for elopement have the potential to be affected by the same deficient practice.
- All residents are being reassessed for elopement. The facility will monitor any resident that is at moderate and high risk and will make sure proper care plan is in place and will monitor resident for any significant changes.
- Facility initiated a binder with photos of residents who are at risk of elopement and will be checked weekly and as needed by Social Service and/or Designee. This will be on an ongoing basis.
- Facility DON and/or Designee will conduct a daily audit of all admissions and readmissions to ensure the elopement assessment has been completed. If a resident is at high risk for elopement, DON and/or Designee will ensure elopement precautions are in place and implemented. This will be conducted daily and will be ongoing.
- Facility initiated the audit of resident elopement assessments of residents who are at risk of wandering and elopement and residents with cognitive impairments to ensure proper care plan is in place.
- Facility removed door lever as well from the problem doors, to ensure doors are locked until alarm company will provide the sensor board. The sensor company will be at the facility to assess the problem in the motherboard.
- Door alarms will be checked daily to be completed by Maintenance, or the Designee or the MOD and audited by Administrator or designee.
- Latch to the door was lubricated and noted functional.
- Facility having door alarms modified to continuously alarm so staff would physically have to go to the location to reset the alarm in the event the alarm triggers.
- Facility initiated in-service on direct staff on Monitoring the Exit Doors, Assessing for Resident Departure, and Reporting to Maintenance Malfunctioning Equipment.
- Any staff member who has not received in-service education by the completion date will be in-serviced before the start of their next shift. Continuing education will be provided on these policies and procedures as needed.
- Facility has contacted low voltage repairer to come to the facility to repair the motherboard on the courtyard doors.
- Facility initiated in-service on direct care staff on residents identified at risk for Elopement along with Elopement Policy. Any staff member who has not received in-service education by the completion date will be in-serviced before the start of their next shift. Continuing education will be provided on these policies and procedures as needed.
- Facility may utilize verbal and in-person methods for in-services.
- The facility has an Elopement Binder with policy and list of residents' high risk for elopement/wandering to ensure appropriate training and in-service is provided.
- Facility will schedule a Resident Council Meeting to discuss facility's policy on going out on pass, utilization of back patio (i.e., smoking, including signing in and out when exiting the building through the front door) and when courtyard patio would be utilized by residents.
- Facility held an emergency QAPI meeting. Medical Director informed of the plan.
- Receptionist received in-service education to ensure all residents who go in and out of the facility follow the sign-in and out protocol.
- Staff to conduct head count on assigned residents during rounds.
- Staff will be assigned to monitor and supervise residents when out in the front of the facility and/or courtyards.
- Administrator will review audits weekly to ensure compliance with the measures put in place to address the safety of residents at high risk for Elopement.
- Administrator will ensure the Abatement Plan will be implemented and completed until compliance date and as indicated.
- QAPI was initiated to discuss with QA Committee the Abatement Plan and ensure all corrective actions and safety measures are consistently implemented. Medical Director notified via phone of the plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to ensure effective fall alarms and supervision: two residents had Smart Caregiver monitoring devices set to LOW volume, and one resident's bed alarm did not alert staff before the resident was found on the floor after an unwitnessed fall. One resident had dementia, osteoporosis, prior TIA, and cognitive impairment and was fully dependent on staff, while staff also found that a second resident's bed and recliner alarms did not activate properly during testing.
Failure to assess the safety of perimeter mattresses for two residents. Both residents had severely impaired cognition and significant mobility limitations, and both care plans included use of a perimeter mattress to define the edges of the bed. However, their Mobility, Physical Device, and Fall Risk assessments lacked documentation of a perimeter/defined edge mattress assessment. Staff interviews showed inconsistent understanding of the required order, IDT review, engineering review, and safety assessment before use.
Improper Mechanical Lift Transfers: A resident with dementia, spinal cord dysfunction, and dependence for transfers was supposed to be moved with a full-body mechanical lift and two staff members, but a TMA stated she transferred the resident alone. The resident reported that staff sometimes used only one person for lift transfers because of staffing shortages, while other staff and the DON stated this was unsafe and against policy.
Two residents were involved in accident-hazard deficiencies. One resident with cancer, PVD, and Alzheimer’s disease was observed in a wheelchair with feet extending past short footrests, with the lower legs resting against the hard footrests despite a care plan entry for padding. Another resident with dementia and a hx of falls had an unwitnessed fall, but ordered orthostatic BP monitoring was not completed accurately and staff reported no post-fall PT referral was received.
A resident was given a new electric wheelchair without a prior therapy assessment and could not stop the chair, causing it to strike a bed frame and resulting in a leg laceration, tibia/fibula fractures, and a syncopal episode from blood loss. Another resident with cognitive impairment and high fall risk continued to self-transfer and fall, but the care plan was not updated with new fall interventions after repeated incidents.
A CNA used a Hoyer lift alone to weigh one resident, and another CNA was observed using a Hoyer lift alone to weigh a second resident. One resident’s care plan called for a 2-assist Hoyer lift, and the facility’s lift competency checklist and policy both required two caregivers for mechanical lift use; the DON and Director of Therapy also stated that two staff members are always required.
Failure to Ensure Effective Fall Alarms and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and effective use of assistive fall-prevention devices for two residents who were reviewed for fall precautions. One resident had diagnoses including unspecified dementia, age-related osteoporosis, a history of transient ischemic attack, and cognitive impairment, and was described by the POA as weak, bedbound, and unable to participate in physical therapy after a prior right femur fracture. The resident was completely dependent on staff for eating, hygiene, mobility, and toileting, and the care plan included a bed alarm per orders. The resident was found on the floor next to the bed after an unwitnessed fall. The POA reported receiving a call from the facility that the resident had been found on the floor and was not injured, and stated the resident frequently forgot to ask for help and had tried to get up without assistance before. A nurse stated the bed alarm was not heard when the resident fell, and the facility was unable to provide evidence that the bed alarm functioned as intended or alerted staff before the resident was found on the floor. The event report identified the fall as unwitnessed and did not indicate that a bed alarm alerted staff. The facility also failed to ensure the Smart Caregiver sensor pad monitoring system used for another resident was functioning properly and set at an audible volume. Two Smart Caregiver monitor boxes at the nurses' station for that resident's bed and recliner were observed set to LOW volume, and the chime settings faced the back wall of the desk. When a CNA tested the recliner alarm from the resident's room, the monitor at the nurses' station did not illuminate or sound an alert on either attempt. The CNA changed the batteries but did not retest the device, and both CNAs stated they could hear alarms only if they were near the nurses' station and did not recall training on operation or testing of the devices. The facility director stated the facility did not perform preventive maintenance on the devices and relied on staff to ensure they functioned properly.
Failure to Assess Safety of Perimeter Mattresses
Penalty
Summary
The facility failed to ensure that 2 residents with perimeter mattresses were assessed for safety. One resident had a significant change MDS showing severely impaired cognition, dementia, reduced mobility, muscle weakness, and need for assistance with bed mobility, sitting, standing, and transfers. That resident’s care plan identified limited physical mobility related to dementia with mood disturbance and anxiety, a genetic muscle disorder, spinal stenosis, and osteoarthritis, and included use of a perimeter mattress to help find the edges of the bed for bed mobility. However, the resident’s Mobility, Physical Device, and Fall Risk assessment lacked documentation of an assessment for a perimeter/defined edge mattress. The second resident’s annual MDS showed severely impaired cognition, dementia, multiple sclerosis, repeated falls, and need for partial to moderate assistance with bed mobility. The care plan identified limited physical mobility related to weakness, falls, incontinence, hypertension, renal disease, dementia, MS, depression, and delusional disorder, and included use of a bariatric sized bed with a perimeter mattress to define the edges of the bed. That resident’s Mobility Physical Device and Fall Risk assessment also lacked documentation of an assessment for a perimeter/defined edge mattress. During observation, the resident was in bed asleep with a perimeter mattress. Staff interviews showed differing understanding of whether a physician order, assessment, IDT review, engineering review, and safety assessment were required before use of a perimeter mattress, and the DON confirmed both residents’ most recent assessments lacked documentation of a perimeter/defined edge mattress assessment.
Improper Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure transfers were performed according to R24’s assessed needs, care plan interventions, and facility policy. R24’s records showed she had diagnoses including non-traumatic spinal cord dysfunction, diabetes, dementia, depression, heart failure, and asthma. She was dependent on staff for toileting and transfers, was frequently incontinent of bowel and bladder, and had care plan directions for assistance with transfers using a full-body mechanical lift and two staff members. During interviews, a TMA stated she transferred R24 with the full-body mechanical lift by herself because R24 needed to use the bathroom and she felt the transfer was safe. R24 stated staff sometimes transferred her with only one staff member and said they told her there was not enough staff. Other staff interviewed stated transfers with the full-body mechanical lift using one staff member were unsafe and should not occur. The facility policy for using a mechanical lift stated that at least two trained associates are needed to safely move a resident with a mechanical full-body floor-based lift or ceiling/overhead full-body lift.
Unsafe Wheelchair Fit and Incomplete Post-Fall Monitoring
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. Resident 27 was readmitted with diagnoses including cancer, peripheral vascular disease, and Alzheimer's disease and was sometimes able to make needs known. On multiple observations, Resident 27 was seated in a slightly tilted back wheelchair with feet extending beyond the footrests, and the back of the lower legs rested against the hard footrests above the ankle/heel area. A pillow was observed either on the floor or behind the legs rather than padding the footrests. The focused care plan for skin integrity included padding to wheelchair footrests, and staff interviews confirmed the footrests were too short and needed adjustment or replacement, but staff had not notified therapy or otherwise addressed the wheelchair fit. Resident 50 was admitted with diagnoses including dementia, history of falls, and UTI and was sometimes able to make needs known. The care plan identified the resident as at risk for falls. After an unwitnessed fall in the 300 hallway, the incident investigation added interventions to monitor orthostatic blood pressures and refer to physical therapy. However, the record showed an orthostatic blood pressure order on 05/20/2026 was not completed, and subsequent orthostatic blood pressures recorded the same blood pressure and pulse for all three positions on 05/22/2026, 05/23/2026, and 05/24/2026. Staff later stated they had not received a post-fall therapy referral, and the DNS stated the resident should have had orthostatic blood pressures taken accurately to rule out orthostatic hypotension.
Failure to assess electric wheelchair use and update fall interventions
Penalty
Summary
The facility failed to comprehensively assess a resident for the use of an electric wheelchair and failed to develop new interventions to reduce fall risk for another resident. The report states that the facility’s policies required a device evaluation before an electric wheelchair was initiated, resident education and consent, and an updated service plan identifying device use and other interventions. The fall management policy required individualized care plan updates, a systematic review after each fall, identification of root cause, and review of prior interventions when new interventions were implemented. Resident 73 was admitted with weakness and lymphedema and had an above-the-knee left leg amputation, requiring assistance with bed mobility, transfers, and locomotion. The resident’s record showed cognitive intactness, lower extremity impairment, supervision or touch assistance for bed-to-chair transfers, and use of a manual wheelchair. On 4/17/26, a newly issued electric wheelchair was delivered and the resident was assisted into it. The resident reported that the representative showed how the chair worked but not enough, and that the resident did not know how to stop it. The resident then returned to the room, could not stop the chair, and the chair continued forward into the bed, causing the resident’s right leg to strike the metal bed frame. The resident sustained a five-centimeter laceration to the right anterior lower leg, fractures of the right tibia and fibula, and a brief syncopal episode secondary to blood loss. The resident also received an anticoagulant, which contributed to significant bleeding. The clinical record contained no evidence that the resident had been assessed to safely operate the electric wheelchair before use. Resident 3 was admitted with a right total hip replacement with deep hardware removal and post-traumatic osteoarthritis of the right hip. The resident had a high fall risk on Morse Fall Scale assessments, cognitive impairment on OT evaluation, and a PT evaluation showing a score of zero on the Short Physical Performance Battery, indicating high fall risk and increased risk of mobility disability. The resident fell on 3/31/26 after getting up independently and sustained a right femur fracture requiring surgical repair, and fell again on 5/12/26 after getting up independently and sustained a skin tear to the right elbow. The care plan identified fall risk and included reminders to use the call light, non-skid socks, and one-person assistance for toileting and transfers, but revisions to the care plan did not add new or amended fall prevention interventions. Staff statements indicated the resident continued to self-transfer and toilet without assistance, staff believed the resident was independent, and the existing fall prevention interventions were ineffective.
Unsafe One-Person Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure safe use of a mechanical lift for 2 of 3 residents reviewed for accidents. During an observation on 6/2/2026 at 8:42 AM, Resident #4 was lying on his bed on top of a Hoyer pad while CNA Staff K stood on the right side of the bed with a mechanical lift; the lift hand bags were observed over the resident, and no other staff member was in the room. Staff K stated that he was weighing Resident #4 and that normally only one person uses the Hoyer lift for weights, although the resident’s care plan documented a Hoyer lift with 2 assist. On 6/4/2026 at 10:15 AM, CNA Staff D was observed using a Hoyer lift alone to obtain Resident #13’s weight, with the resident lifted approximately 12 inches off the mattress in the sling and no other staff present. Staff D stated that he was performing weekly weights and most of the time did the weights using the Hoyer lift by himself. Resident #13’s MDS Section GG coded the resident as dependent, and the facility’s mechanical lift competency checklist stated that two caregivers are present, while the facility policy for using a mechanical lifting device stated that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The DON and Director of Therapy both stated that a mechanical lift should always be used by two staff members.
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