Failure to Prevent Elopement of Cognitively Impaired Resident
Summary
A cognitively impaired resident, who was assessed as being at risk for elopement, was able to leave the facility's secured unit unsupervised. The resident's care plan required staff to conduct visual checks every 15 minutes and to follow specific protocols to prevent elopement. On the day of the incident, a CNA exited the secured unit without ensuring the door was closed and locked behind them, and did not confirm that no residents were following. Surveillance footage showed the resident holding the door open after the CNA exited, then proceeding through the lobby and out the facility's main entrance, which was neither locked nor alarmed at the time. No staff were present in the lobby to monitor the exit. The resident's whereabouts were not documented in the 15-minute monitoring log for several hours, and the assigned CNA later stated that it was unrealistic to monitor and document all assigned residents every 15 minutes due to workload. The facility's receptionist was not present at the front desk during the time of the elopement, and the main entrance door was not secured or alarmed, allowing the resident to exit undetected. The resident was not discovered missing until later in the evening, after which a search was initiated. The resident had a history of exit-seeking behaviors, including wandering, expressing a desire to leave, and packing belongings. Medical records indicated diagnoses such as paranoid schizophrenia, anxiety disorder, epilepsy, and diabetes mellitus, and the resident required regular medication and supervision. The facility's policies required regular checks and supervision for residents at risk of wandering or elopement, but these protocols were not followed, resulting in the resident's unsupervised exit from the secured unit and the facility.
Plan Of Correction
F-tag: 689 Free of Accident Hazards/Supervision/Devices Immediate corrective action: On 4/28/2025, Resident 3 was found by the local police and dropped off at Clinic 1 at "approximately" 6:30 am. The DON notified Resident 3's Primary Physician / Medical Doctor (MD1) and instructed Resident 3 to come back to the facility. On 4/28/2025, two CNAs picked up Resident 3 from Clinic 1 and brought Resident 3 back to the facility at 4:35 pm. On 4/28/2025, RNS 1 conducted a comprehensive assessment of Resident 3 upon return to the facility with vital signs stable. No signs and symptoms of major injury or negative outcome were noted. On 4/28/2025, Primary MD ordered to transfer Resident 3 to a General Acute Hospital for further evaluation and transferred on 4/29/2025. Resident's 3 Conservator was notified and made aware. On 4/24/2025, the DON / DSD provided a verbal 1:1 in-service to CNA 6 regarding the elopement policy. Emphasized to ensure the secured unit door is closed and locked when getting out from the secured unit. On 05/02/25, CNA 6 is no longer in the facility. On 05/02/25, the Administrator provided 1:1 in-service to Receptionist 1 on policy regarding safety and supervision of residents in the secured unit. To ensure the front door in the front lobby is locked and the alarm is set to enhance resident safety. From 05/02/25 to 05/10/25, the DON / DSD provided 1:1 in-service to CNA 7 on the policy of elopement and emphasized following the facility's visual check every 15 minutes to monitor residents' whereabouts and safety. On 4/28/25, the DON posted a visual alert sign at the secured unit exit areas, reminding staff to ensure doors are closed before walking away as part of ongoing safety education. On 4/28/2025, the facility assigned a staff member to the reception area to assist with visitation and supervise individuals entering and exiting the facility. On 4/29/2025, the facility installed a new door keypad for safety in the front lobby. During 4/28/2025 - 4/29/2025, the DON/DSD provided in-services to staff members regarding the elopement policy covering the following topics: a. Supervise and redirect residents who are close to the exits to mitigate the risk of elopement. b. While entering or exiting the secured unit, staff members must check/confirm that no resident is exiting before walking away from the door. c. The importance of conducting rounds every 15 minutes and as needed for adequate supervision. d. The importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision. The DON conducted rounds on 05/02/25 and 05/20/25 in the secured unit to identify any elopement risk residents. No other residents were affected by this deficient practice. Process to prevent recurrence: Effective 4/29/2025, the DON / DSD will repeat the in-service and reinforce the policy of elopement to nursing staff (CNA, LVN, RN) every month for 3 months. Monitoring process: The DON / DSD will conduct daily rounds to observe staff entering/exiting the secured unit to ensure compliance and document the findings in the monitoring log. During the monthly QAPI, the DON will report any deficient findings for follow-up resolution for 3 months. Completion date: 5/20/25
Removal Plan
- The DON provided a verbal one-on-one in-service via phone regarding the elopement policy to CNA 6, following a disciplinary Performance Correction.
- The Registered Nurse Supervisor contacted nearby hospitals and the local police department to locate Resident 3. The ADM contacted private investigators who were also utilized to find Resident 3. A flyer of the missing resident was also provided by the PI.
- The local police found Resident 3 and dropped Resident 3 off at Clinic 1. The DON communicated with Clinic 1's Nurse who confirmed Resident 3 was currently in Clinic 1 with stable vital signs. The DON notified Resident 3's Primary Physician/Medical Doctor who instructed to transfer Resident 3 back to the facility.
- Two CNAs picked up Resident 3 from Clinic 1 and brought Resident 3 back to the facility.
- The Registered Nurse Supervisor conducted a comprehensive assessment of Resident 3 upon Resident 3's return to the facility. Resident 3's vital signs were stable, no signs or symptoms of major injury were noted. The Medical Doctor ordered to transfer Resident 3 to a General Acute Care Hospital for further evaluation. Facility staff notified Resident 3's conservator regarding Resident 3 was found.
- The DON posted a virtual alert sign at secured unit exit areas, reminding staff to keep doors closed before walking away from all secured exit areas, as ongoing safety education.
- The facility assigned a staff member to the reception area to assist with visitation and supervise individuals entering and exiting the facility.
- The DON and the Director of Staff Development provided in-services to staff members regarding the elopement policy, covering the following topics: supervise and redirect residents who are close to the exits, to mitigate the risk of elopement; while entering or existing the secured unit, staff members must check/confirm that no resident is existing from the secured unit before walking away from the exit doors; the importance of conducting rounds every 15 minutes in the secured unit and as needed for adequate supervision; the importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision.
- Elopement Trainings: RNs, LVNs, CNAs, department managers and assistants, activity assistants, housekeeping and laundry employees, and dietary service staff received the in-service training for elopement. Staff need to complete the in-service regarding elopement upon returning to work and prior to providing resident/resident care. Staff not working due to medical, emergency leaves, vacation, and leave of absence will complete their in-services upon their return.
- The ADM notified the Medical Director of the IJ findings in the IJ template. The Medical Director assisted in developing the IJ removal plan.
- The facility also installed a new door keypad for safety in the front lobby.
- There were residents residing in the secured unit.
- The ADM, the DON, and the DSD made rounds, observed staff members entering/exiting the secured unit. No issues were identified.
- The maintenance supervisor inspected all exit doors, gate, and door/gate alarms. No issues were noted.
- The DON would repeat the in-service regarding Elopement policy to staff members every month, for 3 months. The in-services would cover the following topics: supervise and redirect residents who are close to the exits, to mitigate the risk of elopement; while entering or exiting the secured unit, staff members must check/confirm that no residents are exiting the secured unit before walking away from the exit doors; the importance of conducting rounds every 15 minutes and as needed for adequate supervision; the importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision.
- The DON developed an Elopement Monitoring Log, which included supervision and redirection, precautions for entering/exiting the secured unit, and monitoring of the front gate alarm to prevent elopement.
- The facility would conduct a head count at every shift on the secured unit station for 3 months, using the current day's census to enhance supervision.
- The DON, the DSD or the Registered Nurse Supervisor would conduct daily rounds to observe staff entering/exiting the secured unit to ensure compliance and document the monitoring findings/actions in the monitoring log.
- The ADM and the DON developed a Quality Assurance and Performance Improvement for elopement to address the deficient practice in the IJ findings.
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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