Failure to Prevent Elopement Due to Lapses in Supervision, Communication, and Alarm System Functionality
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known risk for elopement exited the facility unsupervised through the main front door. The resident, who had diagnoses including dementia, memory deficit, cerebral infarction, atrial fibrillation, and diabetes, was found by police approximately half a mile away on a busy six-lane roadway after sunset. Facility staff were unaware that the resident had left the premises, and the resident was unable to communicate her address or destination to the police. The facility's policy required systematic monitoring and management of residents at risk for elopement, including timely response to alarms and implementation of care plan interventions, but these measures were not effectively executed. Interviews and record reviews revealed multiple lapses in supervision and communication. Staff members assigned to the resident did not know she was at risk for elopement, and no alarm or beeping sound was heard at the nurse's stations at the time of the incident. The care plan for the resident was not updated to reflect her elopement risk, and there were no interventions documented to address her behaviors of seeking to communicate with family or pacing near exit doors. Additionally, staff failed to redirect the resident or provide additional supervision when she expressed agitation and a desire to contact her daughter earlier in the day. Technical failures also contributed to the deficiency. The main lobby door's alarm system was not functioning as intended: the annunciator device on one wing was muted, and the other wing's device did not have a designated alarm switch for the main lobby door. Reception staff, who were responsible for monitoring the elopement risk binder and door alarms, were not aware of the resident's risk status. The front doors were left unattended and unlocked for a period in the evening, further compromising resident safety. These combined failures in supervision, communication, care planning, and alarm system functionality led to the resident's unsupervised exit and subsequent elopement.
Removal Plan
- Resident #1 returned to facility, placed on one-on-one supervision. Evaluation by LPN revealed no signs of injury or distress. Care Plan updated to reflect current care needs. A head count was conducted of current residents at the facility by RN supervisor. No concerns were identified.
- Current facility residents had elopement risk screens completed. Two additional residents triggered at risk for elopement. Orders and Care Plan were updated to reflect current needs based on updated Elopement Risk Evaluations.
- Elopement risk binders were reviewed to ensure they contain photos and demographic information of residents evaluated to be at risk for elopement. The surveyors reviewed and verified the 3 elopement binders located at the Receptionist desk, C Wing nurse's station and B Wing nurse's station were accurate.
- Elopement Drills to include door alarm drills conducted each shift. Education on elopement process, exit seeking behaviors and exit seeking behavior process/procedures discussed after each drill.
- Education for current staff initiated related to the facility Elopement/ Wandering Residents policy, Abuse, Neglect, Misappropriation and Exploitation, elopement/exit seeking behaviors identification, staff notification of elopement risk, location and contents of elopement risk binders, initiating enhanced supervision for residents actively exit seeking, responding to door alarms and proper actions to take once determined to be exit seeking or at risk for elopement. It also included the change to entry and exit of the facility through designated doors. Licensed nurses received specific education on exit seeking behavior and initiating appropriate care plan, orders and adding the elopement risk alert to the gray bar (this is in the electronic medical record and shows immediately below the picture of the resident in both the nurses charting system and the CNA charting system), immediately updating the elopement risk binders, creating a new elopement risk assessment in the computer and notifying nursing management. Receptionist received specific education followed by specific competencies on monitoring the door alarm system and notification to maintenance if a failure is identified, understanding the importance of the elopement binder and reviewing it at the beginning of each shift worked, and the proper procedures of resident LOA, signature for each oncoming and off-going shift on the clipboard indicating they had both appropriately initiated or deactivated the screamer alarm and for their review of the elopement binder, the process of utilizing the video doorbell for visitor/vendor entry and exit and notification of nursing manager if exit seeking behavior is identified.
- Education was conducted with IDT team on the process of identification, care planning, prevention, and response of elopement/exit seeking behaviors in morning meeting by progress/behavior note review and a review of the elopement risk UDAs, admission and readmission assessments (that contain the elopement risk evaluation for new residents) completed.
- Huddles are conducted at the beginning of each shift to discuss elopement risk and fall risk residents. This is an added communication to ensure staff are aware of at-risk residents.
- Door function and alarms were checked by the Administrator and the Maintenance Director, all doors and alarms were functioning appropriately. During the review by Maintenance Director, the C wing annunciator was noted to be muted. The volume of the annunciator was increased, and the button was disabled to remove the ability of staff to adjust the volume by vendor.
- Education provided by Staff Development Coordinator, DON and Administrator. All facility staff received education on the facility elopement/ Wandering Residents policy, Abuse, Neglect, Misappropriation and Exploitation, elopement/exit seeking behaviors identification, staff notification of elopement risk, location and contents of elopement risk binders, initiating enhanced supervision for residents actively exit seeking, responding to door alarms and proper actions to take once determined to be exit seeking or at risk for elopement. It also included the change to entry and exit of the facility through designated doors. All licensed nurses received education on exit seeking behavior and initiating appropriate care plan, orders and adding the elopement risk alert to the gray bar (this is in the electronic medical record and shows immediately below the picture of the resident in both the nurses charting system and the CNA charting system), immediately updating the elopement risk binders, creating a new elopement risk UDA and notifying nursing management. All receptionists have been educated on monitoring the door alarm system and notification to maintenance if a failure is identified, understanding the importance of the elopement binder and reviewing it at the beginning of each shift worked, and the proper procedures of resident LOA, signature for each oncoming and off-going shift on the clipboard indicating they had both appropriately initiated or deactivated the screamer alarm and for their review of the elopement binder, the process of utilizing the video doorbell for visitor/vendor entry and exit and notification of nursing manager if exit seeking behavior is identified.
- Newly hired staff and staff members on leave will receive education at orientation or prior to working their next scheduled shift.
- Root Cause Analysis (RCA) completed and reviewed by QAPI. Additional contributing root causes were identified and addressed in QAPI, as outlined below. These factors were staff response, staff knowledge of elopement risks and resident safety, appropriate plan of care/interventions for residents, muting of the C wing annunciator.
- The facility conducted an ad hoc QAPI meeting which included the Facility Administrator, DON, Medical Director via telephone, and additional staff members. The Performance Improvement Plan was accepted by the committee. The annunciator and the correction plan of the annunciator was reviewed in QAPI as indicated by the review of the maintenance enhancement plan. Door alarm annunciator volume increased on C wing, mute button on C wing annunciator disabled. Reviewed staff education completed including identification and response/process of exit seeking behaviors, elopement drills conducted. No additional recommendations were made at that time.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Follow Fall Interventions: A resident with dementia, ESRD on dialysis, impaired mobility, and a history of falls was observed ambulating and self-transferring in her room and bathroom without staff assistance, despite orders and a care plan requiring one-person assist with a walker, call light use, frequent safety checks, and skid strips by the bed. Staff interviews confirmed the resident was transferring independently and that the skid strips were not in place as documented.
A resident assessed as high risk for falls did not receive the physician-ordered fall mat on the right side of the bed. Surveyors observed no mat during multiple checks, and the TAR did not reflect the intervention. The resident said the mat had been removed after a new bed was placed, while an RN and the DON acknowledged the order remained in place even though the mat was no longer being used.
Smoking safety interventions were not consistently implemented for four residents who smoked. Two residents were observed smoking with staff supervision but without the smoking aprons listed in their assessments and care plans, and two other residents were also observed smoking in wheelchairs without aprons despite care plan interventions requiring them. The DON confirmed the apron requirement for two of the residents, while the ADON stated residents sometimes complained about the aprons and that he did not know when smoking assessments were completed.
A resident with cerebral palsy, severe cognitive impairment, wheelchair use, and a care plan requiring a mechanical lift for all transfers was manually transferred by a CNA instead of using the lift. During observation, the CNA lifted the resident by the upper back and moved him between the wheelchair and bed without mechanical assistance, despite having completed lift competency training and despite the DON confirming the resident required a mechanical lift for all transfers.
Failure to supervise a resident at risk for elopement led to repeated exit-seeking and wandering events, including being found off the unit and near exterior areas. The resident had dementia with cognitive impairment, hemiplegia, and diabetes, and staff notes described missing documentation of several wandering episodes, an incomplete care plan intervention, and incidents involving a broken alarmed door, a Wanderguard, and an unknown visitor letting the resident off the unit.
A resident with severe cognitive impairment fell during a lift transfer when a sling strap came loose and the chest strap clip broke, and two other residents were observed being transferred with total body lifts using slings that were not verified against their care plans or mobility assessments. Staff interviews showed some CNAs relied on the sling already in the room or on how it fit, rather than consistently checking the care plan or Kardex for the correct sling size and transfer method.
Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure that a resident's fall interventions were in place for one resident reviewed for falls. The resident had diagnoses of dementia and end-stage renal disease requiring dialysis, was documented as having intact cognition but needing supervision with ADLs, transfers, and walker use, and was identified as a fall risk due to ESRD, impulsive behavior, and impaired mobility. The resident's nursing and provider orders directed staff to assist with ambulation, remind the resident to use the call light and wait for staff, and complete frequent safety checks each shift. The resident had a documented fall in which she was found sitting on the floor between her drawer and walker with bleeding from a forehead injury and a skin tear to her jaw, and she was transferred to the hospital where she received stitches. The incident report stated the resident lost her balance when she walked to her drawer to close it. The resident's care plan later identified a self-care performance deficit related to actual falls, weakness, and impaired mobility, and included interventions such as assistance from one staff member with a walker and gait belt, assistance with transfers and toileting, use of assistive devices, skid strips next to the bed, and frequent monitoring for safety. During observations, the resident was seen ambulating and self-transferring in her room and bathroom without staff assistance and at times without using her walker or call light. Staff observed the resident walking independently in her room, and an unidentified staff member passed by without entering the room. The resident stated that she walked and used the bathroom by herself and did not need to follow instructions. Staff interviews confirmed that the resident transferred independently and ambulated without a walker or staff assistance, while another nurse stated the resident was not supposed to self-transfer and that skid strips were not present despite being listed in the care plan. The DON stated that staff were expected to follow resident orders and care plans for safety.
Missing Ordered Fall Mat for High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a resident assessed as high risk for falls received the physician-ordered fall prevention intervention of a fall mat positioned on the right side of the bed. Resident #50 was admitted with diagnoses including orthostatic hypotension, lack of coordination, reduced mobility, and communication deficit. The resident’s fall risk assessment showed a score of 50, indicating high risk for falling, and the care plan identified the resident as at risk for falls and fall-related injury due to a history of falls with fracture, cognitive impairment, and decreased safety awareness. During multiple observations, the resident was seen at the bedside and no fall mat was present on the right side of the bed or located in the room. The physician order dated 6/7/2026 specified a mat on the right side of the bed, but the MAR and TAR did not reflect the fall mat as an implemented intervention. The resident stated the fall mat had been removed after a new bed was placed and had been gone for a long time. An RN stated the resident was a fall risk and that the order for the fall mat should be followed or cancelled if no longer needed. The DON stated the bed had been changed out and the mat would get in the way, and the order should have been cancelled.
Smoking Safety Interventions Not Followed
Penalty
Summary
The facility failed to ensure adequate assessment and implementation of smoking safety interventions for four sampled residents who smoked. Residents #12 and #85 were observed smoking in the designated smoking area with staff supervision on multiple occasions, but neither was observed wearing a smoking apron even though the smoking binder and care plan indicated they needed one. During an interview, the ADON confirmed both residents were listed as needing aprons and stated the residents sometimes complained about the apron, but they should not smoke unless they put it on. The ADON also stated he does not go out with smokers often and does not know when assessments are completed. Resident #12 had diagnoses including COPD, muscle weakness, and epilepsy, and smoking evaluations noted tobacco use and balance problems while sitting or standing; smoking was added to the care plan with a clothing protector intervention. Resident #85 had diagnoses including hemiplegia and right-hand contracture, and although initial smoking evaluations indicated tobacco use with no impairments, smoking was later added to the care plan with a clothing protection requirement. Resident #52, who had CVA with right-sided weakness and paralysis, diabetes, mood disorder, major depressive disorder, and right hand and upper arm contracture, was observed smoking in a wheelchair without a smoking apron despite a care plan intervention requiring one. Resident #11, who had TBI, schizoaffective disorder, major depressive disorder, paraplegia, and upper extremity contractures, was also observed in the smoking area in a wheelchair without a smoking apron, and no attempt was made by the smoking monitor to get the apron on. The DON confirmed that Residents #52 and #11 were supposed to wear smoking aprons when smoking, and the facility smoking policy required residents to be educated and evaluated for smoking upon admission, re-admission, and quarterly.
Failure to Use Required Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to ensure Resident #5 was transferred with a mechanical lift as required. Resident #5 was admitted with diagnoses including cerebral palsy, BPH, and hypertension, and a quarterly MDS showed severe impairment in thinking with a BIMS score of 4. He required substantial to maximal assistance with toileting hygiene, used a wheelchair for mobility, and his care plan documented a history of falls with interventions initiated for a mechanical lift for all transfers to wheelchairs. A POC task also indicated he required a mechanical lift for transfers every shift, and he was listed among residents requiring a sling/mechanical lift. During observation, CNA C provided incontinent care and transferred Resident #5 from his specialized wheelchair to the bed and back without using a mechanical lift. Instead, she manually lifted him by placing her arms around his upper back and interlocking her fingers. In interview, CNA C stated she had been employed for a month, had completed lift competency during orientation, but did not use the lift because she felt comfortable transferring him without assistance and had never used the mechanical lift on him, although other staff did. The DON stated Resident #5 required a mechanical lift for all transfers and that staff could see this in the POC. The facility policy stated mechanical lifting devices shall be used for lifting and moving residents when necessary.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident elopement for a resident who was identified as at risk for elopement and did not reside on a secured unit. The resident had diagnoses including hemiplegia, diabetes, and dementia, and the MDS indicated cognitive impairment. The record showed multiple elopement evaluations with changing results, including several assessments that identified the resident as at risk for elopement in July 2026, while earlier assessments had indicated not at risk or were incomplete. The care plan identified the resident as an elopement risk/wanderer related to impaired safety awareness, but the record contained only one incomplete intervention related to wandering, and no resident preferences were included. Behavior monitoring documented exit-seeking and wandering behaviors on multiple occasions in May, June, and July 2026, but progress notes did not document the behaviors noted on 5/21/26, 6/21/26, and 7/14/26. A physician order for a Wanderguard was created after the resident was found wandering outside on the curb, and staff notes described discussions with family and assessments after the resident was returned to the unit. The resident was later involved in additional elopement-related events. Staff statements and progress notes described the resident being found near a door, in the front hall, in the assisted living area, and off the unit near common areas, with staff searching for her after she was reported missing. One note stated the resident could escape through a security door because the alarm was broken and had not been fixed yet. Another investigation note stated the resident was found off the unit in a common area adjacent to the unit after being let off by an unknown visitor. The facility determined that the resident was cognitively unable to recognize the door requiring a code and would be physically unable to open it without assistance. The report states the facility was out of compliance with resident safety and supervision since 4/12/26.
Failure to verify correct sling size and safe lift use during resident transfers
Penalty
Summary
The facility failed to ensure staff followed accident prevention interventions and safe device use for three sampled residents who required total body lift transfers. The report states that four certified nursing assistants did not verify the correct sling size before transferring residents, despite care plans and the lift’s sling-size identification system directing staff to use specific sling sizes based on resident weight and transfer needs. Resident 39 had severe cognitive impairment, Alzheimer’s disease, dementia with behavioral disturbance, anxiety disorder, and muscle weakness. Her care plan and mobility assessments showed a progression from sit-to-stand lift use to total body lift use with two staff members and a medium sling. On 5/1/26, she was transferred from her wheelchair to her bed by a CNA using a sit-to-stand lift when the sling strap came loose from the hook on the lift and the chest strap clip broke, causing her to fall backward onto the floor. She sustained a skin tear on her right forearm, bruising to the right side of her face, redness to the right side of her body, and a bruise on her right frontal scalp. She was sent to the ER, where X-rays showed no acute findings or fractures. Observations later showed resident 39 being transferred with a total body lift using a large sling, and resident 8 and resident 25 were also observed with large total body lift slings on. Resident 8 had paraplegia, moderate cognitive impairment, and a care plan directing total body lift transfers with a medium and extra-large sling, while his mobility assessment indicated an extra-large sling and two staff members. Resident 25 had vascular dementia and muscle weakness; her care plan directed total body lift transfers with two staff members, and her mobility assessment indicated a large sling. Interviews with CNAs showed that staff sometimes relied on the sling already in the room or judged sling size by how it fit, rather than consistently referring to the care plan or Kardex. The DON and MDS coordinator stated that staff were expected to use the resident’s care plan or Kardex to determine sling size for safe transfers.
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