Failure to Prevent Elopement of Cognitively Impaired Resident Due to Lapses in Supervision and Wander Guard Use
Summary
A severely cognitively impaired resident, with diagnoses including senile degeneration of the brain, anxiety disorder, encephalopathy, and type 2 diabetes mellitus, was identified as high risk for wandering and elopement upon admission. The resident's assessments indicated severe cognitive impairment, disorientation, and a history of wandering, with interventions including the use of a wander guard device. On the night of the incident, the resident had experienced a seizure and was transported to the hospital by paramedics, during which the wander guard was removed. Upon the resident's return from the hospital, there was no verifiable evidence that the wander guard was reapplied, and the nurse responsible for re-admission was unaware of the need for the device. Throughout the night, staff observed the resident wandering the building, attempting to redirect him with snacks, television, and conversation, but were unsuccessful in keeping him in his room. Multiple staff members noted the resident's persistent wandering and attempts to exit, with door alarms sounding at various times. Despite these behaviors and the resident's known risk, staff did not verify the presence or function of the wander guard, and there was no documentation indicating it was reapplied after the hospital visit. Additionally, staff allowed family members of other residents to enter and exit the facility using the door code without staff assistance, which created an opportunity for the resident to follow someone out of the building. The resident ultimately exited the facility unnoticed during the early morning hours and was found by a concerned citizen walking in the middle of the road, approximately 0.55 miles away from the facility, dressed in a t-shirt, pajama pants, and without shoes, in 46-degree weather. Facility staff were unaware of the resident's absence until notified by local law enforcement. The facility's failure to ensure the wander guard was in place and to provide adequate supervision and control of exit doors directly led to the resident's elopement.
Removal Plan
- Local law enforcement called facility and spoke with Licensed Practical Nurse (LPN) #107 to notify about Resident #12 being found and taken to the hospital.
- LPN #107 and Registered Nurse (RN) #108 completed a head count of all residents to ensure all were present and accounted for.
- LPN #107 attempted to notify Resident #12's Responsible Party and left a message.
- LPN #107 notified RN Manager #109 of Resident #12 leaving the facility and being taken to the hospital; RN Manager #109 notified the Administrator.
- RN Manager #109 attempted to contact Resident #12's Responsible Party and left a message.
- RN Manager #109 called and spoke with the hospital nurse for an update on Resident #12.
- RN #111 spoke with Resident #12's Responsible Party and notified them of the incident.
- Resident #12 returned to the facility accompanied by paramedics; RN #111 obtained vital signs and assessed Resident #12.
- Resident #12's wander guard was placed back on by RN #111 and Resident #12 was placed on one-on-one (1:1) supervision.
- Facility staff were educated on the Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions were in place for residents with exit seeking behaviors, ensuring interventions were put back in place when residents returned from the hospital, and not giving residents or families the door code.
- RN #101 audited resident orders and care plans for wander guards; any variances were corrected immediately.
- Receptionist #114 and Maintenance Director #115 audited all residents with wander guards for functioning, placement, and expiration; all were placed properly, functioning appropriately, and not expired.
- Maintenance Director #115 audited all exit doors and the wander guard system at all doors to ensure proper function.
- RN #101 audited current resident progress notes to ensure if behaviors consistent with exit seeking were noted, then residents had appropriate interventions in place.
- Resident #12's Nurse Practitioner (NP) #116 was notified of Resident #12 leaving the facility and being taken to hospital by law enforcement with return to facility.
- Administrator audited the facility records of exit door function checks.
- ADON #103 completed elopement and wandering risk assessments on all in-house residents.
- An elopement drill was completed by Maintenance Director #115.
- An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the facility correction plan including ongoing compliance.
- ADON #103 educated all current resident responsible parties via phone that they were to ensure staff let them in and out the doors when the front door was locked and should not enter the code themselves or let anyone else out without staff assistance.
- SecureCare was called and the front door code was changed by Maintenance Staff #117.
- The Care Conference form was updated by the Administrator to include education for new families and a reminder for others to request staff assistance with doors when locked, not put in code themselves or assist anyone else out of facility.
- Resident #12's care plan was updated by RN #101 to include wandering and elopement risk with interventions including 1:1 as needed, monitor and report changes in behaviors, orient to new surroundings, provide diversional activities of interest as needed, redirect as needed, and wander guard with placement and function checks as ordered.
- Nursing staff would monitor the effectiveness of interventions for Resident #12 by reviewing point of care (POC) documentation and conducting a review for weekend POC.
- CNAs would report behaviors to the charge nurse if behaviors were not resolved with interventions.
- 1:1 (staff) supervision would continue for Resident #12 until discharge.
- If a call off occurred for a person doing 1:1 supervision, the Administrator would be immediately notified and re-assign floor staff, management staff, or other department staff to cover 1:1 as appropriate. The Administrator would oversee 1:1 coverage scheduling.
- All new hires and agency staff would be educated regarding the facility's Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions are in place for residents with exit seeking behaviors, ensuring interventions are put back in place when residents return from the hospital, and not giving residents or families the door code.
- The Administrator or designee would review all door checks to ensure all doors were checked and functioning appropriately. All variances would be corrected upon discovery and education/follow-up would be provided as deemed necessary.
- Maintenance Director #115 or designee would conduct elopement drills to ensure staff respond accordingly. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
- The DON or designee would assess all residents with wander guards to ensure proper placement, function and expiration. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
- The Administrator or designee would audit the wander guard system and resident accessible exit doors to ensure they were functioning properly to ensure all doors were intact and functioning properly, including alarm. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
- The DON or designee would complete elopement and wandering risk assessments for facility residents to ensure no changes in behavior patterns or acute changes in condition affecting mental status were present placing residents at risk for elopement and ensuring that appropriate and effective interventions were in place. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
- The DON or designee would audit progress notes to ensure any residents with behaviors that increase risk for elopement or exit seeking have appropriate interventions in place.
- The Administrator or Designee would interview visitors to ensure visitors were aware they were not to enter door codes when the door was locked and should wait for staff assistance to exit facility, as well as not let anyone else out without staff assistance.
- The facility Quality Assurance (QA) committee would review audits to ensure compliance. Variances would be corrected immediately upon discovery and education provided.
- Results of these audits would be reported to the facility quality assurance committee. Ongoing compliance would be maintained by recommendations of the facility quality assurance committee.
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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