Failure to Prevent Elopement of Resident with Severe Cognitive Impairment
Summary
The facility failed to ensure effective systems were in place to provide adequate supervision for a resident with severe cognitive impairment. On the day of the incident, the resident, who had a diagnosis of unspecified dementia and required assistance with all activities of daily living, was found to be missing when a CNA noticed his lunch tray was untouched and he was not in his room. The nurse was alerted, and a search of the facility and grounds was initiated. Despite these efforts, the resident had already left the facility undetected. The resident was able to exit the building, reportedly during a time when there were many visitors entering and leaving, possibly by following a visitor out. The facility's entry and exit procedures at the time required guests to sign in and out, but there was no mention of a system in place to prevent residents from leaving alongside visitors. Staff interviews confirmed that the resident was not exhibiting exit-seeking behaviors prior to the incident, and it was not immediately clear how he managed to leave the premises. The absence of effective monitoring and security measures allowed the resident to leave unnoticed. The resident was missing for approximately eight hours before being located by law enforcement over five miles away from the facility. During this period, staff followed internal protocols for missing residents, including notifying law enforcement, the resident's guardian, and conducting searches of the facility and surrounding areas. The incident exposed a failure in the facility's supervision and security systems, particularly for residents at risk of elopement due to cognitive impairment.
Removal Plan
- Nurses completed a head count using the facility's census to ensure no other residents were missing, verified by the nursing supervisor.
- Resident was reevaluated by the psychiatrist and new orders were received.
- Reeducation regarding the prevention of elopement was initiated for the staff by the Director of Nurses (DON).
- All nursing staff on all shifts received education regarding residents who exhibit exit-seeking behavior, the risk of elopement, and the need for adequate supervision to ensure resident safety.
- Unit Managers, supervisors, and/or designee(s) and/or MDS Coordinator(s) re-evaluated residents at risk for elopement by completing a new elopement risk screening form.
- MDS Coordinator and/or designee reviewed and updated the care plans of the residents at risk for elopement to reflect the current elopement risk.
- Nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee(s).
- A Root Cause analysis was completed using the Five Whys to develop new approaches to prevent reoccurrence.
- The Facility conducted an AdHoc Quality Assurance Meeting to review the Performance Improvement Plan ensuring proper interventions are put in place.
- The facility conducted an elopement drill on every shift.
- Staff were re-educated on the Elopement and wandering, residents' exit seeking policy.
- The DON, ADON, and designee completed elopement risk screening on active residents and reviewed their plan of care to ensure appropriate interventions are in place, and the plan of care was updated.
- Facility wide audit of the elopement screenings identified new residents that triggered for elopement risk.
- Residents triggered for at risk for elopement have orders for a wander alert system to be put in place.
- Orders were obtained from the physician for psych reevaluation for residents triggered for elopement risk.
- The elopement book was updated with new pictures of residents triggered for elopement risk.
- Elevator keypads installed on the elevators by the Elevator Company.
- A keypad/alarm installed at the door leading to the lobby by the alarm company.
- Elopement drills are done on every shift.
- The Maintenance Director or designee to conduct Safety rounds Log to check exit door, screamer alarms and outside gates.
- Residents with new behaviors of exit seeking and wandering will be added to the elopement risk book that is kept at the nursing station and is accessible to all staff. The behaviors will be added to the resident's care plan and the Kardex.
- Nursing staff will communicate during the shift to shift report any resident who exhibits behaviors to leave the facility, and the safety measures put into place.
- The nurses and nursing supervisors will use the facility census to conduct the headcount of the residents in their respective unit during shift change and they will sign the census to validate that the count is correct, and all residents are accounted for.
- The CNAs will conduct rounds every two hours to ensure the residents are safe and accounted for. CNAs will report to the nurse immediately if unable to locate a resident. Facility protocols for missing residents will be used immediately to locate the residents.
- New admissions elopement evaluations will be reviewed during clinical meetings to ensure elopement interventions are in place for residents that are at risk and the facility guidelines are followed. Nursing Supervisors will review the new admissions elopement evaluation for compliance.
- The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place.
- Residents with new behaviors of wandering, exit seeking will be reassessed by the ADON, Unit Managers, Supervisors or designee for a risk for elopement.
- The DON, Administrator, ADON and/or designee will enforce disciplinary action for facility staff who fail to follow the elopement policy and procedures.
- New hires will receive education on wandering, elopement, and resident safety by the DON, ADON or designee(s).
- The DON and ADON reeducated employees on the facility's policy & procedures as it is related to elopement and residents' safety.
- Elopement drills were conducted with staff participation tracked and compliance rates monitored, with ongoing drills for staff who have not yet participated.
- All elopement elements put into place were verified and the facility is 100% compliance.
- After the facility wide audit of the elopement screening, the facility identified new residents who triggered for elopement.
- A QAPI (Quality Assurance and Performance Improvement) review for follow-up was done, all the elements were verified, and facility was 100% compliance.
- The facility will conduct an elopement drill.
- The DON, ADON, and administrator will review the clinical record of any residents with behaviors of exit seeking and wandering to ensure the facility policy and procedures are implemented and followed, and residents have remained safe at the facility.
- Review the findings during the QAPI meeting.
- The DON, ADON/designee will conduct a quality review of residents on each unit.
- The findings of these reviews will be reported in the next Risk Management/QA Committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring by the Regional Director of Clinical Services when completing their quality systems review.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to maintain effective wandering and elopement safeguards for cognitively impaired residents. One resident with Alzheimer’s disease and severe cognitive impairment exited through an unsecured maglock door and was found by police hours later, while another resident’s wander alert bracelet failed to alarm when tested. Staff, including the DON, ADM, and DOR, reported there was no policy or documented process for testing the current wander alert system or monitoring bracelet function, and the facility had no system for checking the maglock doors before the incident.
A facility failed to report an alleged sexual abuse incident to DOH and law enforcement within the required timeframe after a resident told an LPN they had been raped by a CNA. The resident, who had intact cognition and significant neurologic and urinary diagnoses, later described intimate care that involved pain and burning, and said they felt embarrassed and ashamed when a male NS and male officers were present. The facility also allowed the male NS to complete an assessment without another staff member present and did not provide SW involvement or psychosocial interventions despite the resident being emotionally distraught and not sleeping well.
The NHA and DON failed to manage the facility effectively to ensure allegations of abuse were reported timely and that interventions were implemented to protect residents from abuse. Review of job descriptions, facility documentation, and staff interviews showed the facility did not meet its responsibilities to protect residents from potential abuse, resulting in an Immediate Jeopardy situation.
Failure to Monitor Wandering and Elopement Safety Systems: The NHA and DON did not effectively oversee systems intended to protect a resident at risk for wandering/elopement. A resident with a history of removing an electronic monitoring device and expressing intent to leave, smoke, and return home exited through an exterior door without staff knowledge or supervision and entered an unsafe outdoor environment.
Failure to prevent resident elopement occurred when the NHA and DON did not effectively manage the facility to protect residents from exiting unsupervised, and a resident left the building without supervision. The report states this created an Immediate Jeopardy situation for one of 29 cognitively impaired residents.
Staff were observed and reported using personal cell phones in resident care areas, including a CNA sitting in a resident common area with a personal phone in hand. Residents stated aides were often on their phones while working, and one resident reported being told they were rude for interrupting a staff member who was on the phone with her boyfriend. Resident Council minutes also noted concerns that some aides were on their phones too much, despite the handbook prohibiting cell phone use in the work area.
Unsafe wandering and elopement safeguards were not effectively managed
Penalty
Summary
The facility was cited for not being administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of residents because it failed to ensure a safe environment for cognitively impaired residents who wander or are at risk for elopement. The report identified two separate events involving wandering safety systems and noted that the deficiency affected seven residents identified as at risk for unsafe wandering and elopement. Resident #1 had diagnoses including Alzheimer's disease, alcohol abuse, and COPD, and the Minimum Data Set dated 06/08/2026 assessed the resident as having severe cognitive impairment. On 06/04/2026, the resident was located by local police approximately 12 hours later and about three miles away. Staff interviews indicated that the resident exited through a door associated with the third-floor east stairwell area, and the Maintenance Assistant stated the maglock may have slipped and disengaged, causing the door to inactivate and the alarm not to sound. The Director of Maintenance stated the third-floor east wing stairwell door used a keypad and magnetic locking system, that the first-floor exit door near the parking lot had no alarm system, and that the facility had no system for checking the doors prior to the incident. Resident #2 had diagnoses including hypertension, diabetes mellitus, and depression. The Minimum Data Set documented the resident as independent with chair/bed-to-chair transfers and wheelchair mobility and as having no wandering behaviors. During testing on 06/29/2026, the resident's wander alert device failed to alarm. Staff interviews further revealed there was no documented policy for testing the wander alert system or resident bracelets, and the facility had no current system for monitoring bracelet functionality weekly per manufacturer recommendations. The Director of Maintenance stated they could not find a policy for the wander alert system and only obtained manufacturer guidance after contacting the manufacturer, while the Administrator stated they assumed the system monitored bracelet functionality.
Failure to Report Alleged Sexual Abuse and Address Resident Distress
Penalty
Summary
The facility failed to report an alleged sexual abuse incident involving a resident immediately or within 2 hours to the Department of Health and local law enforcement after the allegation was made. The resident was admitted with diagnoses including obstructive and reflux uropathy, hemiplegia, and hemiparesis following cerebral infarction, and had a BIMS score of 15 indicating intact cognition. A facility incident report documented that the resident told an LPN that they had been raped by a CNA, and the resident later described that the CNA was providing brief care, applying cream to the hip and then to the anus and vaginal area, and that they felt something enter the anus and vagina. The resident stated they told the CNA they were hurting them, that the CNA apologized and made a moaning sound, and that they later felt burning in the vaginal area. The facility also failed to protect the resident during the response to the allegation by allowing a male nursing supervisor to perform a nursing assessment with no other staff member present after the rape allegation. The resident and family member stated that when law enforcement arrived, male officers and the male nursing supervisor were present, and the resident said they felt embarrassed and ashamed and did not want to discuss the rape. The resident stated they only reported that the CNA was rough with them. The family member stated the resident was hysterically crying and said a staff member had raped them, and the family member contacted law enforcement and requested hospital transfer. The facility further failed to provide social work involvement or psychosocial interventions after the allegation. The resident stated they were not sleeping well after the incident and were emotionally distraught and tearful during the interview. The administrator stated the facility did not report the alleged rape to the state because the resident later changed the story to rough handling, and stated they did not think the resident required social work or psychosocial interventions. The primary care physician stated the facility should call law enforcement and the Department of Health if the resident alleged they were raped.
Failure to Ensure Timely Abuse Reporting and Protective Interventions
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to ensure residents were free from abuse by ensuring staff reported allegations of abuse in a timely manner and by implementing interventions to prevent abuse. Review of the NHA job description showed the NHA is responsible for ensuring the facility operates in compliance with local, state, and federal regulations, and review of the DON job description showed the DON is responsible for leading the Nursing Department to provide quality care based on best practices and regulatory guidelines. Facility documentation and staff interviews showed the facility failed to ensure allegations of abuse were reported timely and that interventions were implemented to protect residents from potential abuse. This failure placed residents at risk for serious injury from abuse and resulted in an Immediate Jeopardy situation. Based on the deficiencies identified, the NHA and DON failed to fulfill essential duties and responsibilities of their positions, contributing to the Immediate Jeopardy situation.
Failure to Monitor Wandering and Elopement Safety Systems
Penalty
Summary
The facility failed to provide effective administrative oversight and to implement and monitor systems intended to protect residents identified as being at risk for wandering or elopement. The Nursing Home Administrator’s job description stated the administrator was responsible for managing the facility in accordance with policies, procedures, and applicable standards, while the Director of Nursing’s job description assigned responsibility for directing nursing services, collaborating with the Administrator and Medical Director, conducting daily rounds, reviewing nursing documentation, monitoring resident care, and assuming daily operations in the Administrator’s absence. Despite these responsibilities, the facility did not effectively use available resources to identify and correct system problems related to resident safety. On June 19, 2026, Resident CR1 exited the facility through an exterior door without staff knowledge or supervision and entered an unsafe outdoor environment while holding a cigarette. The resident had a documented history of removing safety devices, including the electronic monitoring device intended to activate the exit alarm system, and had repeatedly stated an intent to leave the facility, smoke, and return home. Even with these known risk factors, administrative oversight did not ensure effective systems were in place to identify when required safety interventions were absent or to prevent the resident from leaving the building unnoticed.
Failure to Prevent Resident Elopement
Penalty
Summary
The Nursing Home Administrator and Director of Nursing failed to effectively manage the facility to protect residents from elopement, resulting in Resident R1 exiting the building unsupervised. Review of the facility job descriptions showed the NHA was responsible for directing overall operations in accordance with applicable regulations to ensure the highest level of care, and the DON was responsible for managing and directing resident care within the nursing department to maintain standards of resident care and ensure each resident functioned at his or her highest level. The facility failed to prevent residents from exiting the facility unsupervised, and during an interview the NHA and DON confirmed that administration failed to effectively manage the facility to protect residents from elopement. The report states this created an Immediate Jeopardy situation for one of 29 cognitively impaired residents.
Staff Used Personal Cell Phones in Resident Care Areas
Penalty
Summary
The facility failed to ensure staff did not use personal cell phones in resident care areas. Resident interviews indicated that staff were often seen using personal phones while working, including one report that a staff member told a resident they were being rude for interrupting while the staff member was on the phone with their boyfriend. Other residents reported seeing staff walking by their rooms while on their cell phones, and one resident stated staff members working in the facility were often seen using personal cell phones. During observation on 06/24/26 at 5:25 A.M., CNA #838 was observed sitting in a darkened corner of a resident common area with a personal cell phone in hand, with the phone light illuminating the CNA's face. When approached by the surveyor, the CNA dimmed the phone and placed it in the pocket of scrub pants. The CNA stated she was unsure of the facility's policy on personal cell phones but knew they were prohibited during work hours, and confirmed she did not have a work cell phone. Resident Council meeting minutes also documented resident concerns that some aides were on their phones too much, and the employee handbook stated that cell phone use in resident areas may violate regulations and was prohibited in the work area.
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