Inadequate Supervision Leads to Resident Elopement
Summary
The facility failed to ensure adequate supervision for a resident, resulting in an elopement incident. The resident, who had a history of dementia and was moderately impaired, was found outside the building on a loading dock, having exited the facility without staff knowledge. The resident's clinical records indicated a moderate risk for elopement, yet the facility did not update care plans or implement sufficient interventions to prevent such incidents. The resident had multiple episodes of wandering and confusion, which were documented in progress notes. Despite these documented behaviors, the facility did not consistently complete elopement risk assessments or notify the resident's family and physician. The facility also failed to update care plans or implement additional safety measures to address the resident's wandering and exit-seeking behaviors. The facility's lack of response to the resident's elopement risk was further evidenced by the absence of wander guard alarms on doors and elevators that did not lock when a wander guard bracelet was detected. This oversight, combined with the failure to conduct regular elopement risk assessments and update care plans, contributed to the resident's ability to leave the facility unsupervised, creating an immediate jeopardy situation.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? (Resident R1) - Resident R1 now has a Wander Guard and was moved to the first floor where the Wander Guard alarms are located. Resident R1 was assessed for injury and family was notified on 4/16/2025. The physician was notified of the elopement on 4/05/2025 at 16:30. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - Elopement risk assessments were completed on all residents on 4/16/2025. Any resident identified as at-risk for elopement was reviewed by the interdisciplinary team for appropriate interventions to prevent elopements. Sign-in/Sign-out sheets were initiated on 4/19/2025 to monitor all resident whereabouts on and off the nursing units. 3. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? The Elopement - Assessment, Risk & Prevention Policy was revised to include: - Added that the Elopement Risk Assessment will be performed quarterly as part of the resident's care plan review. This is in addition to performing the assessment on admission (or readmission), for changes in the residents' condition or cognition, after an elopement attempt, upon verbalizing their desire to leave the facility, and any time a staff member feels that the resident should be reassessed. - Rounds were added on an hourly basis from 11:00 PM to 7:00 AM every night and every hour for weekend shifts. These rounds will be recorded in logbooks on every nursing unit. - Sign-in/Sign-out logs were added to every unit to update staff when the residents are off the unit for an activity, appointment, or outing. Binders are at every nursing station with at-risk resident photographs and their individualized care plans. Binders are at the front desk with at-risk resident photographs. - In the event of an elopement, a full body assessment will be included. All departments (agency and staff) were educated about elopement risks and procedures, that included recognizing elopement, completing risk assessments, care plans, supervision to prevent elopement, and the Wander Guard system. - Further education will be ongoing and will be included in the new hire curriculum and at least annually with all staff education days. An emergency QAPI meeting was held on April 22, 2025, to review elopement policies and procedures. Another QAPI meeting is scheduled for May 5, 2025, to review elopement policies and procedures and progress with implementation. - CNA meetings were held on April 22, 2025, and a Licensed Nurse meeting was held on April 23, 2025, to educate clinical staff on the changes to the Elopement Policy and to discuss concerns. A Daily Stand-Up Meeting and Policy was developed and will begin on May 1, 2025. These meetings will review the 72-hour nursing report every Monday and will review the 24-hour nursing report every other weekday. The Stand-Up Meeting will address new business and reportables, high-risk review elements, and any events to be reported to the attending physicians and/or the medical director. A binder with the Stand-Up Meeting notes will be maintained by the nurse educator. - Elopement drills will be held on at least a quarterly basis, with every shift evaluated on at least a yearly basis. An elopement drill is scheduled to be conducted on 5/02/2025. A directed In-Service on 42 CFR 483.25 Accidents/Hazard/Supervision F689 will be held on May 7, 2025, by Masters crafted in Healthcare, LLC. This In-Service will include a review of all the federal regulations cited along with a review of the accompanying guidelines and be conducted on all shifts and recorded for any staff unable to attend. All staff will also be educated on new and revised policies at this time. The staff will continue to ensure that the new policies will be followed. This will be monitored at the daily Stand-Up Meetings, and audits of the rounding logbooks. All will be reported quarterly at QAPI. 4. How will the corrective action be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? The Elopement Prevention Audit Tool, which includes physician orders, treatment record documentation, elopement binders, incident reports, hourly logbooks, event reporting, and physician notification is being completed by the DON or designee daily for 2 weeks starting on 4/16/2025, then weekly for 3 weeks, then monthly for 3 months, and then quarterly thereafter with the results reported to the Quality Assurance Committee for further follow-up. 5. Dates of when the corrective action will be completed - May 16, 2025.
Removal Plan
- An elopement assessment will be done on every resident.
- Resident R1 now has a wander guard and is moved to the first floor where the alarms are located.
- Resident R1 has been assessed for injury and family was notified of all the events.
- Elopement care plans, which include resident specific interventions, will be done on every resident.
- Hourly rounds will be added to all night and weekend shifts.
- Wander guard placement will be checked every shift, and wander guard function will be checked daily.
- At risk residents must be supervised when out of bed by a staff member to ensure residents are safe.
- Educate all departments including agency on Elopement Risk and Assessment, Care plans, Supervision, Wander guards, How to activate wander guards and where they are located, Color light indicators.
- Elopement policy revised to add head to toe assessment (full body), elopement risk assessments will be done quarterly with care plan review, elopement binders will be on each nurse's station and front desk, to include picture and room number.
- Emergency Quality Assurance Performance Improvement (QAPI) meeting will be held with all supervisors and committee members.
- All other incidents will be reviewed at regular QAPI meetings.
- Audits will be completed.
- Daily audits will be completed by DON or designee daily for two weeks, then weekly for three weeks, then monthly for three months, and then quarterly.
- Hourly Round tool will be conducted at night and on the weekends.
- Facility called an emergency QAPI meeting, and signature sheet was provided and reviewed.
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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