Failure to Supervise and Identify Resident Leads to Unsupervised Exit
Summary
A cognitively impaired resident, recently admitted to a secured facility, was able to exit the building unsupervised after a restorative nurse aide (RNA) opened a locked gate without verifying the individual's identity. The RNA mistakenly believed the resident was a visitor and did not check for an identification wristband or confirm with licensed nursing staff before allowing the person to leave. Video surveillance confirmed that the resident walked through the locked gate and exited the facility without staff present in the lobby. The resident had a history of dementia, psychosis, and was considered gravely disabled, with multiple medical diagnoses including hypertension, diabetes, and a history of self-neglect. Upon admission, the resident required assistance with activities of daily living and was not provided with an identification wristband, as the facility did not utilize them at the time. Staff interviews revealed that there was no policy or procedure in place for verifying the identity of individuals leaving through the locked gate, nor was there a system for monitoring the gate or ensuring residents wore identification wristbands. The incident was discovered when staff were unable to locate the resident, prompting a search and notification of local authorities. The facility's policies on wandering, elopement, and supervision referenced general safety measures but did not address specific procedures for resident identification or monitoring of secure exits. Staff involved acknowledged that the failure to verify identity and lack of a monitoring system contributed directly to the resident's unsupervised exit from the facility.
Plan Of Correction
Immediate Corrective Action: On 04/24/2025, the facility, under Administrator and Director of Nurses instruction, initiated the missing resident protocol. The staff called local hospitals. The facility searched facility premises and close surroundings. Local Law enforcement was called for support. MD was informed. Resident's representative was informed. The facility continued search on 04/25/2025. On 4/25/2025 at around 5:00 pm, Resident 1 was located and found in her apartment approximately 7.8 miles away from the facility, by RN 1 and LVN 1 and 2, with support from local police officers. On 4/25/2025 at around 5:56 pm, Resident 1 returned to the facility accompanied by RN 1, LVN 1 and 2, and local police officers. Resident 1's vital signs were checked by RN 2: B/P - 154/52, Temperature - 98.5, Respiration - 17, Pulse - 73 (regular), and oxygen saturation was 96% on room air. Resident 1 was alert and oriented x2. Resident denied pain and no emotional distress was noted. Resident 1's skin condition was also checked upon return by RN 2 and noted to have a scab on LT knee and discoloration on LT gluteal area, which were already identified on admission on 4/25/2025. Resident 1 ate at around 6:50 pm and consumed 100% of her meals. On 4/25/2025, Resident 1's attending physician was notified of her return at around 6:00 pm, and the known emergency contact was also notified and aware of her return at around 6:00 pm. On 4/25/2025 at around 8:30 pm, Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation. On 4/26/2025, Resident 1's blood sugar level was 186, taken at the GACH at around 11:50 pm. On 4/25/2025, RNA 1 was given a disciplinary action and was suspended by the Administrator until further notice pending investigation. This resulted in immediate termination on 04/25/2025. From 6:30 am on 4/25/2025 to 4/26/2025, the Director of Nursing, QA Nurse Consultant, and Director of Staff Development conducted a series of in-service training and re-education to staff about Safety and Supervision of Resident policy, Elopement, Missing Person, and Resident Identification policies, with emphasis on the following: - The purpose and importance of identifying and confirming with Licensed Nurse/RN Supervisor/DON or Administrator/Receptionist whether the person leaving is a visitor and not a Resident of the facility first and foremost before allowing anyone to leave the premises for safety. - The purpose and importance of keeping Residents safe and well-being, particularly in a secured setting, by supervising Residents while in the facility as needed and being mindful of their whereabouts at all times to ensure their safety. - The purpose and importance of identifying Residents by checking if they are wearing an ID wristband or have another form of identification (e.g., photographs) to help identify Residents and ensure they receive appropriate care and services. - The purpose and importance of immediate action/interventions, such as initiating a code (GREEN) to start a search immediately once a Resident is found missing. - The purpose and importance of seeking assistance from Local Police on a search. As of 4/25/2025, there are 113 employees who have received in-service training and re-education, and on 4/26/2025, an additional 10 employees received training, totaling 95% of current employees who have completed their required in-services/re-education regarding the topics mentioned above, excluding 7 employees currently on leave of absence (LOA)/vacation. This training and re-education are ongoing and will continue until all 130 active staff/employees are captured. On 05/14/2025 through 5/15/2025, re-education and training were conducted by a Licensed Psychologist. The facility has 130 current employees, of which 123 completed their required in-services, re-education, and post-test, reaching a total of 95%. Out of the 130 employees, 7 are excluded due to LOA/vacation. This training and re-education are ongoing and will continue until all staff are trained. Staff members who were unavailable to attend the in-service/training for any reason will be given an in-service before returning to work. A post-test was also provided to assess understanding and knowledge of the topics covered. Effective 4/25/2025, this in-service/training and re-education will be provided monthly for 4 months, then annually and as needed thereafter. On 4/25/2025, the Medical Director was notified of the incident, and QAPI was initiated by the Administrator to analyze and investigate the root causes of the deficient practices. On 4/26/2025, a new policy regarding the Secured Unit/Facility was reviewed with the Interdisciplinary Team (IDT) members, including but not limited to, the Administrator, Director of Nursing, Director of Staff Development. The new policy was reviewed and approved by the quality assurance meeting on 05/12/2025 and will incorporate the following guidelines: - Admission process - Environment considerations - Visitation procedures Action taken to identify all other residents: On 4/25/25, RN Supervisor/Social Service Director checked all Residents and conducted a headcount, verifying residents based on census to ensure all residents were accounted for and present in the facility, excluding residents in hospital on bed-hold. No residents were found to be affected by the deficient practice. On 4/26/2025, Licensed Nurses, the Medical Records Director, and Designee checked all residents to see if they were wearing identification wristbands. Four residents were found not to be wearing wristbands due to refusal. An IDT meeting was conducted to discuss residents' non-compliance, respecting their rights, and informing their physicians and responsible parties. Refusals to wear wristbands are addressed in the care plan. Also on 4/26/2025, the Social Service Director or Designee and Licensed Nurses evaluated all residents to ensure they felt safe and secure in the facility using a safety/wellness evaluation tool. No residents were affected by this deficiency. Process and action taken to prevent recurrence: 1. The facility will assign a staff member to monitor the reception area daily, 7 days a week, to oversee the front lobby and monitor individuals entering and exiting. The assigned receptionist will inform the Social Service Director and/or Designee five times a week (Monday-Friday), and the "Manager of the Day" on weekends, as coverage. An alarm has been installed on the main entrance door to alert staff when someone enters or exits, especially in the absence of the receptionist or staff manning the front lobby. 2. Visitors will sign in and record the date/time of the visit, reason for the visit (destination), prior to entering the facility, and will sign out when leaving. Visitors may be required to present a photo ID to verify their identity before entry. 3. Visitors will wear a visitor sticker for identification during their visit. They may be asked to show a photo ID if they refuse or lose the sticker, or if there is a need to confirm their identity against the visitor log and Resident ID system (e.g., wristband). 4. Effective 4/25/2025, the Administrator installed a buzzer at the gate to alert staff when assistance is needed at the gate area to identify individuals wanting to leave before exiting. The Administrator/Designee will check the buzzer's function randomly twice a week for three months, then monthly thereafter. If the buzzer malfunctions, Maintenance will replace it immediately. After hours, RN Supervisor will be informed for assistance. 5. Staff will use the buzzer to alert Licensed Nurse/RN Supervisor for assistance in identifying and/or assisting individuals leaving the premises, verifying with the physician if out-on-pass is permitted, and whether the Resident is leaving with an authorized person. 6. The Administrator will review the visitor's log randomly twice a week for three months, then weekly, to ensure proper sign-in/out and purpose documentation. 7. RN Supervisor/Designee will apply an ID wristband upon admission or readmission of Residents, including taking a photograph to upload into the Resident's electronic records (PCC). 8. A GREEN wristband will be provided to Residents who are ambulatory without assistance to identify them and alert staff about the risk of elopement, especially near exit doors. 9. The Administrator will schedule random room rounds five times a week (Monday-Friday) for three months, then three times a week thereafter, assigning at least three rooms per Department Head or IDT member for inspection. The "Manager of the Day" on weekends will conduct additional random room inspections, including checking if Residents are wearing wristbands. 10. Licensed Nurses will conduct visual monitoring every 30 minutes for 72 hours to check on newly admitted Residents' whereabouts, activity, and behavior. Monitoring performance to ensure correction is achieved and sustained: Findings from monitoring reports will be reviewed and presented to QA monthly for further resolution and recommendations. Any issues of non-compliance will be reviewed by the QA Committee for additional actions until no negative trends are observed and 100% compliance is maintained for three consecutive months. The Administrator and/or Director of Nursing will oversee ongoing compliance. How corrective action will be accomplished for residents affected by the deficient practice: The Administrator completed 40 CEU units for license renewal on 04/27/2025. The renewal application and payment were mailed to the CDPH Licensing Department on 04/28/2025, pending review and approval. How the facility will identify other residents at potential risk and take corrective action: All residents within the facility have the potential to be affected by the deficient practice. On 04/28/2025, the Regional Director of Operations provided an in-service to the Administrator on maintaining licensure and addressing disciplinary actions for deficiencies.
Removal Plan
- The Administrator gave a disciplinary action and suspended RNA 1 pending investigation.
- Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 1, and 2 local police officers located Resident 1 in Resident 1's apartment, approximately 7.8 miles away from the facility.
- RN 1, LVN 1, and 2 local police officers accompanied Resident 1 back to the facility. RN 2 completed Resident 1's skin assessment and noted a scab on Resident 1's left knee.
- Resident 1 was transferred to General Acute Care Hospital (GACH) 1 for further evaluation.
- The DON, the Quality Assurance (QA) Nurse Consultant, and the Director of Staff Development (DSD), conducted a series of in-services to staff regarding 'Safety and Supervision of Residents,' 'Elopement,' 'Missing Person,' and 'Resident Identification' policies, emphasizing: a) Identifying and confirming with Licensed Nurses, RNs, the Administrator, or Receptionist that the person leaving the facility is a visitor and not a resident before allowing anyone to leave the secured premises; b) Supervising residents while in the facility and always being mindful of their whereabouts; c) Identifying residents by checking for ID wristbands or another form of identification such as a photograph; d) Immediate action and interventions such as initiating a code to initiate search immediately once a resident was found missing; e) Seeking assistance from the Local Police Department in searching for a missing resident.
- LN, Medical Records Director, and Designee checked all residents to see if in-house residents were wearing ID wristbands. Four residents who refused were addressed in their care plans after an Interdisciplinary meeting.
- The Social Service Director (SSD) or designee and LNs evaluated all residents to see if the residents feel safe while in the facility using the safety/wellness evaluation tool. No other resident was found to be affected by the deficient finding.
- The IDT members comprising of the Administrator, the DON, and the DSD reviewed a new policy pertaining to secured unit/facility integrating the guidelines on admission process, environment special consideration, and visitation: a) The RN or Licensed Designee will immediately apply an ID wristband to a resident upon admission and upload a photograph in the resident's electronic health record; b) Green colored ID wristbands will be provided to residents who are ambulatory without assistance for identification and to alert staff about the risk for elopement; c) The Administrator will assign Department Heads or IDT members to conduct room inspections and check residents for ID wristbands, and assign a 'Manager of the Day (MOD)' on weekends to conduct random room inspections; d) LNs will conduct visual monitoring every 30 minutes for 72 hours to check newly admitted residents' whereabouts, activities, and behaviors; e) The facility will assign a staff member to monitor the reception area daily seven days a week, and an alarm has been installed on the main entrance door to alert staff when someone is entering or exiting in the absence of the receptionist.
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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