Failure to Prevent Resident Elopement Due to Inadequate Supervision and Security
Summary
A deficiency occurred when the facility failed to protect a resident from neglect by not providing necessary supervision to prevent elopement. The resident, who had a history of Parkinson's Disease, cognitive impairment, and other significant medical conditions, was identified as being at risk for elopement and resided in a secured unit. Despite this, the resident was able to exit the facility undetected through the main entrance while the receptionist was distracted by visitors. The main entrance required manual unlocking after a buzzer was engaged, and the receptionist, responsible for monitoring the entrance camera, did not notice the resident leaving. There were no additional staff present at the entrance at the time of the incident. The resident's care plan and medical orders clearly indicated an elopement risk, and she was supposed to be provided with safe wandering interventions and supervision. On the day of the incident, the resident was last seen in the dining room and then was not found during medication pass and dinner. Staff initiated a search after realizing the resident was missing, but by that time, the resident had already left the building. The facility's layout allowed access from the secured unit to the main lobby and entrance through unsecured hallways, and the entrance system allowed visitors to enter without a code, though a code was required to exit. This system was in place at the time of the incident, and staff interviews confirmed that visitors could access the secured unit without a code, potentially allowing residents to leave unnoticed. The resident was found by law enforcement several hours later, approximately two miles from the facility, with minor injuries such as abrasions and bruising. She missed several doses of her prescribed medications during the period she was missing. Interviews with staff indicated that the resident had not previously exhibited exit-seeking behaviors and that staff were not aware of any immediate risk on the day of the incident. The failure to provide adequate supervision and effective security measures directly led to the resident's elopement and the resulting deficiency.
Removal Plan
- 100% headcount of residents was completed to ensure no other residents were missing. All other residents were accounted for.
- A whole house search of the facility was completed.
- The executive director was notified by the weekend supervisor who in turn notified facility managers to report to work to assist in the search. Regional and divisional staff were also notified and reported to the facility to assist in the search. The medical director and primary physician were notified.
- An external search of the community was initiated.
- Executive Director notified the local Police Department who assisted in the search.
- Upon return, the resident was placed on one-to-one supervision on the secured unit. (1:1 monitoring ordered).
- All facility exit door alarms and screamer devices were inspected by the Maintenance Director.
- Keypad code to secure unit was changed by the Maintenance Director.
- Immediate education on abuse neglect and exploitation and risk of elopement initiated.
- 3-11 shift sign-in sheet reviewed. 11-7 signage sheet reviewed. No concerns.
- The elopement risk assessments of all residents were reviewed for accuracy.
- An elopement drill was performed for the 11-7 shift.
- The resident was assessed by the nurse upon return and by the physician. Skin assessment done.
- An elopement drill was performed for the 7-3 shift.
- The care plans and kardexes of residents at risk for elopement were reviewed for accuracy.
- Visitor lanyards were ordered for identification of visitors/vendors to differentiate visitors from residents. The lanyards were put into use immediately.
- Keypad order to replace push button for entry to units. Keypad was installed.
- Elopement books were reviewed for accuracy.
- An ad hoc QAPI was performed by the facility IDT and reviewed by the Medical Director.
- The Executive Director initiated education related to abuse/neglect reporting.
- The Assistant Executive Director notified the Department of Children and Families of the elopement of Resident #1.
- A Federal Immediate Report was submitted.
- Current facility staff were provided education by the Director of Nursing and Assistant Director of Nursing pertaining to what constitutes resident mistreatment, abuse, neglect, and misappropriation of resident property. Any employees who have not received the training were notified they must receive the training prior to working their next scheduled shift. New employees hired after will receive education during the facility orientation process. Education pertaining to abuse/neglect is provided annually and as needed.
- Facility practices which assist in monitoring/identifying potential abuse and neglect include, but are not limited to: grievance process, complaints resolution process, facility theft and loss reporting, resident council, incident reporting, internal audits of resident trust accounts, daily staffing practices, and regular direct indirect supervision of nursing home employees and resident care by supervisory and administrative staff.
- Root cause analysis was performed by the regional director of clinical services related to the circumstances of the resident elopement. An IDT review and investigation of the residence episode of elopement was completed through the ad hoc copy process. Included in the investigation was reviewed the residence condition preadmission and post admission, resident evaluations including the accuracy of elopement evaluation resident care plan, staffing, facility environments and equipment.
- The residency elopement risk evaluation was completed accurately at the time of admission and a care plan for elopement risk was initiated. The resident was correctly placed on the locked [NAME] wing unit at the time of admission.
- The staffing PPD for licensed nurse assist and for CNA's. On the [NAME] Wing units on the 3:00 PM to 11:00 PM shift, there were two nurses and five CNA's for the 52 residents. 2 weeks staffing calculations (State only Requirement) reviewed with no concerns.
- Staff who predominantly work on the [NAME] Wing were interviewed via a questionnaire and asked if the resident displayed any exit seeking behaviors prior to the incident, verbalizations of wanting to leave, packing belongings, or pushing on exit doors. The staff report no indications of such desire to exit or knowledge of any exit seeking behavior.
- The investigation and root cause analysis revealed potential root cause scenarios (birthday party and push button entrance).
- Elopement risk evaluation facility systems processes in place related to patient identification of potential for elopement/ wandering and safety in place and followed.
- The elopement risk evaluation is completed on admission, quarterly, and after a significant change period the evaluation consists of ambulatory mobility status, wandering behaviors, cognitive status, and exit seeking indicators.
- If a patient is identified as a potential risk, based upon the evaluation, a patient identification form, which will include a current photo, a current description, and personalized care plans, and interventions, and redirection strategies. The patient elopement book contains copy of the patient identification form, a colored photo of the patient and a face sheet. The elopement books are maintained at each nursing station and at the entrance to the reception facility area.
- Facility door prevention maintenance, monitoring and checked for function weekly conducted as scheduled.
- All exit doors are inspected weekly.
- All designated entrance/exit areas have scheduled staff assigned to the receptionist area from 8:00 AM to 8:00 PM seven days a week.
- Staffing schedules are monitored daily by staffing coordinator and reviewed with executive director of nursing and or nursing supervisor on duty to ensure adequate staffing is maintained. Adequate staffing means all minimum PPD, and ratios are met and in addition, staffing is adjusted based on acuity of patient needs.
- All staff are screened prior to hire and a job specific orientation is performed. Receptionist not only receive training but have a completed competency on file.
- A review of five receptionist staff employees' file revealed all had completed training and had a competency on file. The receptionist on duty at the time of the residence elopement was suspended immediately and has subsequently been terminated.
- The maintenance staff performed an inspection of the facility exit doors and screamer devices and all were found to be fully functional.
- Weekly door checks by the Maintenance Director will be performed to ensure proper function. The push button entry system onto the memory care unit was replaced with the keypad the truth device.
- Facility licensed nurses completed a review of the accuracy of 185 current residents elopement risk evaluations. Of the 185 residents, 52 residents resided in the memory care unit and 51 of those who were already assessed to be at risk for elopement. The remaining 1 of 52 residents was originally placed on The [NAME] Wing unit for behavior management but has since become a risk for elopement. The residence assessment was updated to reflect the risk of elopement.
- The care plans and CNA Kardexs' of 52 of 52 residents at risk for elopement were reviewed. All were found to be in compliance with risk for elopement identified.
- Director of Nursing /designee to complete monitoring of new admission evaluations to ensure risk for elopement is accurately identified and care plan and Kardex are reflective of the risk, where appropriate.
- The Medical Director was informed of the citations and is in agreement with the removal plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to protect two residents with severe cognitive impairment from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent after repeated sexual encounters were discovered. Staff found the residents together in bed or in the bathroom, often unclothed, and allowed privacy based on their behavior without documenting a structured consent assessment. The facility also did not fully investigate unexplained bruising and reported vaginal bleeding for one resident in the setting of the known relationship, and the MD was not notified of the incidents or injuries.
Failure to protect a resident from resident-to-resident physical abuse: one resident entered another resident’s area, got into her belongings, and then grabbed, hit, and scratched her left wrist/hand, causing a skin tear, bruise, swelling, and pain. The injured resident said she was afraid of the other resident, while staff heard yelling, found both residents in the room, separated them, and documented the wound and bruising. The other resident had dementia with behavioral disturbance and used a walker and wheelchair.
Failure to protect a resident from resident-to-resident abuse: a resident with PTSD and a long history of physical and sexual abuse reported another resident repeatedly entered their room at night, then later exposed himself, blocked the resident from leaving, and used meth in front of them. The record lacked an investigation, trauma assessment, psychosocial monitoring, and documented behavior-based monitoring for the other resident, and staff interviews confirmed the concerns were not fully addressed in the chart.
A resident with dementia, CKD, HF, and severe cognitive impairment was involved in a physical abuse allegation when a CNA struck or batted his arm/hand during care after he grabbed at staff. A witness reported that the CNA hit the resident hard and yelled at him, while the CNA said she only tapped his hand away and did not consider it abusive. The resident could not answer questions about the event, and the facility’s records showed the allegation was not promptly escalated through the abuse reporting chain.
A resident with impaired cognition, stroke-related deficits, and constipation was subjected to manual stool removal by an LPN after a suppository did not work. Staff interviews and the resident’s statements indicated she said stop and begged the LPN to stop while he continued the procedure, and she later described the care as painful, violating, and demeaning. The LPN said he manually removed the stool in the bathroom, did not complete an abdominal assessment, and did not contact the provider for further direction.
A resident with CKD, CHF, ESRD, DM, and multiple foot wounds did not receive ordered daily wound care, and the TAR and progress notes lacked documentation that the treatments were completed on multiple occasions. The resident was later hospitalized for worsening wound infection, with purulent drainage and concern for osteomyelitis; the wound care provider also reported concerns that ordered dressing changes were not being done and noted worsening skin breakdown to the buttocks.
Failure to Assess Consent and Investigate Injury With Resident Sexual Activity
Penalty
Summary
The facility failed to protect two cognitively impaired residents from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent to sexual activity after becoming aware that they were engaging in sexual contact. One resident had diagnoses including Alzheimer’s disease, neurocognitive disorder with Lewy bodies, dementia, and anxiety, with documentation showing severe cognitive impairment, wandering, hallucinations, confusion, and inability to consistently orient to time or place. The other resident also had diagnoses including Alzheimer’s disease and dementia with psychotic disturbance, with repeated BIMS scores showing severe cognitive impairment and care plan documentation noting cognitive loss and a history of wandering and checking doors. The record showed repeated incidents in which the two residents were found together in bed or in the bathroom, often unclothed, and staff documented that they appeared calm or did not show obvious distress. Staff notes and interviews showed that the residents were allowed privacy and continued access to each other without documentation of a formal assessment of whether either resident understood the nature of the relationship or could knowingly and voluntarily consent. Staff interviews also reflected that they relied on the residents’ behavior, such as whether they pushed away or said no, rather than documenting a structured assessment of capacity after each incident. The facility also failed to investigate unexplained bruising and reported vaginal bleeding for one resident in the context of the known sexual activity. The record documented bruises on the forearms and thigh in various stages of healing, along with a report of bloody vaginal discharge, but there was no evidence of a physical assessment or investigation to determine whether the findings were related to abuse, coercion, trauma, or another cause. Interviews with the RN, LPN, DON, MD, and family showed that the physician had not been notified of the sexual incidents, the bruising, or the vaginal bleeding, and that staff had not documented a formal assessment after the incidents.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident physical abuse when one resident attacked another during the night, causing a skin tear to the left wrist, bruising to the left thumb, swelling, pain, and fear for safety. The injured resident was admitted with diagnoses including type 2 diabetes mellitus, unsteadiness on feet, need for assistance with personal care, and muscle weakness, and had a BIMS score of 15/15 indicating cognitive intactness. The other resident involved had diagnoses including type 2 diabetes mellitus, dementia with other behavioral disturbance, and essential hypertension, and used a walker and wheelchair for locomotion. According to the injured resident, she returned from the bathroom and found the other resident in her area getting into her refrigerator. When she told the other resident to get out of her things, the other resident became angry, grabbed her left wrist, hit her left hand, and scratched her, causing the injury. The injured resident stated she was afraid of the other resident and was glad the other resident had been moved to another unit so she could not hurt her again. At observation the next day, the resident’s left wrist/hand was bandaged, an observable bruise was present at the base of the left thumb, and the hand/wrist was slightly swollen and painful to touch. Facility documentation and staff statements confirmed that staff heard yelling from the room, found the residents in the room, and separated them. Nursing notes documented a skin tear with partial skin flap loss to the left wrist/forearm and bruising to the left thumb, with the wound cleansed and steri-strips applied. Staff statements described the other resident as being in the injured resident’s area and making unwanted contact, while the administrator stated the investigation was still ongoing and could not yet determine whether resident-to-resident abuse had occurred. The facility’s abuse prevention policy states residents are to be free from abuse by anyone, including other residents, and defines physical abuse as willful infliction of injury resulting in physical harm or pain.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse and failed to provide adequate supervision and effective interventions when Resident 7 reported fear and unsafe interactions with another resident. Resident 7 was admitted with COPD and PTSD and had a documented history of childhood through adulthood abuse, including physical and sexual abuse, domestic violence, and trafficking. A trauma questionnaire showed Resident 7 had previously tried to avoid reminders of past events and reported that nothing made them feel worse at that time. In one incident, Resident 7 told staff they were afraid to go to sleep because another resident came to their room at night and shook them awake. The resident admitted going to the room and waking Resident 7, and staff educated that resident about safety and respect. The progress note did not appear in the incident log or grievance log, and the record did not show an investigation, monitoring for negative psychological social outcomes, a trauma assessment, or care plan interventions to promote a sense of security. Staff interviews confirmed the social service department was unaware of the situation and that a trauma assessment should have been completed. In a second incident, Resident 7 reported that the same resident blew methamphetamine smoke in their face in the smoking shed, blocked them from leaving with a wheelchair, and exposed and masturbated in front of them. Resident 7 stated the event triggered past childhood trauma and made them feel trapped. The facility investigation documented a separation plan and one-to-one supervision for Resident 7, while the other resident was placed on alert status with increased monitoring and behavior risk. However, the record did not show implementation of behavior-based monitoring for the other resident, and observations later showed Resident 7 without staff supervision.
Physical abuse allegation involving a resident during care
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse when a CNA slapped the resident’s arm during care. The resident was a male with dementia without behavioral disturbance, chronic kidney disease, and heart failure. His care plan identified that he could be physically aggressive due to poor impulse control and resistive to care because of impaired cognition, and his quarterly MDS showed severely impaired cognition with a BIMS score of 2, extensive assistance needs for most ADLs, and bowel and bladder incontinence. According to the incident documentation, the event occurred in the resident’s room during care when one CNA reported that another CNA hit the resident’s hand after the resident grabbed her. A written statement from the witnessing CNA said the CNA hit the resident hard on the arm and then yelled at him. The resident was unable to answer questions about the event because of his stroke and cognitive impairment, and the incident report noted that he had a history of hitting staff. The CNA involved stated that the resident struck her arm and that she tapped his hand gently, comparing her action to what one would do with a child. The facility’s investigation summary described the contact as the CNA batting the resident’s hand away, while the witness described it as striking the resident on the arm. The report also showed that the allegation was not immediately escalated through the facility’s abuse reporting process, as the witness said she reported it to an LVN and was told the DON had been notified, but the abuse coordinator did not receive the information until later. The facility’s records also reflected that the incident was ultimately treated as an unsubstantiated allegation of abuse.
Abuse During Manual Stool Removal
Penalty
Summary
The facility failed to ensure a resident was free from abuse during bowel care when an LPN performed manual removal of impacted stool from the rectum without consent and continued after the resident asked him to stop. The resident had moderately impaired cognition, was dependent on staff for transfers and toileting hygiene, and had a history of constipation. Her diagnoses included stroke, atrial fibrillation, hemiplegia/hemiparesis, adjustment disorder, and mixed anxiety and depressed mood. Her care plan identified limited physical mobility and the need for two staff with a stand lift for transfers. On the day of the incident, the resident had not had a bowel movement for several days and had received constipation medications and a rectal suppository. Progress notes documented that a rectal check found hard stool and that manual evacuation was performed with removal of large amounts of stool. Staff interviews described that the resident cried, said stop, and begged the LPN to stop while he continued the manual removal for additional time. The resident later reported that the procedure was painful, that she felt violated, embarrassed, and demeaned, and that she believed the nurse was smiling and laughing at her during the care. Multiple staff interviews confirmed that the resident was distressed during the procedure and that the LPN did not stop when she requested it. Staff also stated the procedure was invasive and should have been stopped when the resident expressed pain. The LPN stated he manually removed the stool in the bathroom, did not complete an abdominal assessment, did not administer an enema before manual removal, and did not contact the provider for further direction. The report also states the facility failed to ensure the resident was free from abuse during cares, and the immediate jeopardy was identified based on this event.
Failure to Complete Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care services as ordered by the physician for one resident with multiple chronic conditions, including CKD, CHF, HTN, ESRD, muscle wasting/atrophy, anemia, and diabetes-related foot wounds. The resident’s records showed a BIMS score of 15, indicating cognitive intactness, and documented multiple wounds, including ulcers on both feet, a diabetic foot ulcer, and a wound infection. Physician orders required daily wound care to the left calcaneus, right calcaneus, right plantar foot, right medial foot, and daily povidone-iodine application to the right foot, but the TAR did not document completion of these treatments on multiple dates in May 2026, and the progress notes also lacked documentation that the treatments were completed. The resident was hospitalized on 5/26/26 with worsening wound infection. The hospital history and physical documented ESRD on daily dialysis, CHF, COPD, DM, depression, HTN, prior MI with stenting, oxygen use, chronic wound status, and ulcers of both feet with necrosis of muscle. The hospital record stated the resident reported the nursing home should have been changing wound dressings daily but said that was not done. The wound care provider stated the right foot wound had purulent drainage, she was concerned about osteomyelitis, and she sent the resident to the emergency room. She also stated she had concerns that the facility was not completing the ordered dressing changes and that the resident had worsening buttocks skin breakdown, while the DON stated treatments should be completed as ordered and documented on the TAR or in progress notes.
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