Failure to Supervise High-Risk Wanderer Resulting in Unnoticed Elopement
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to elopement. A cognitively impaired resident with dementia, severe disorientation, and a history of wandering exited the building from the fourth floor to the outside, unnoticed by staff. The resident was ambulatory, able to walk significant distances independently with a steady gait, and had documented wandering behaviors, including going into other residents’ rooms and requiring frequent redirection for safety. Despite these characteristics and prior identification as an elopement risk on risk evaluations, the resident did not have an active electronic monitoring device in place at the time of the incident. The resident’s records showed that she had previously been identified as an elopement risk and had an elopement-focused care plan that included use of an electronic monitoring device and monitoring of that device for function. Physician orders for checking the electronic monitoring device each shift had been in place earlier in the year but had ended months before the elopement. The care plan, however, still reflected interventions related to an electronic monitoring device. Staff interviews revealed that the resident typically wandered on the fourth floor, was easily redirected, and had not been seen off the unit before. Multiple clinical providers, including the primary care provider, ARNP, PMHNP, and therapy staff, described the resident as ambulatory, oriented only to person, unable to care for herself, and at risk for following others toward exits or elevators. On the day of the incident, staff on the unit saw the resident around change of shift and redirected her to her room, but they were unaware that she had left the floor and the building. An alarm sounded from a stairwell exit door on the lower level, but staff did not initially know why it was sounding or whether a resident had gone out. Another cognitively intact resident, who was outside on a leave of absence, observed the confused resident walking around the west side of the building in a hospital gown and blanket, approached her, and brought her to sit on a bench at the front of the building, where a staff member then saw them and assisted the resident back inside. Facility leadership and staff were unable to determine how the resident traveled from the fourth floor to the first floor or how she accessed a stairwell door that should have been locked with a keypad. The facility’s own abuse/neglect policy defined neglect to include failure to adequately supervise a resident known to wander from the facility without staff knowledge, and the surveyors determined that this failure resulted in a situation that created a likelihood for serious injury or death and constituted Immediate Jeopardy. Interviews with the NHA and DON indicated that the resident had initially been considered an elopement risk earlier in the year, then was viewed as not at risk after a hospital stay when she was non-ambulatory. They acknowledged that an Elopement Risk Assessment completed in May was incorrect because it was based on pre-hospital information, and that the resident was not listed in the elopement binders at the time of the incident. They also confirmed that although the resident’s mobility improved and she began walking well again and wandering, an electronic monitoring device was not reapplied because she was not perceived as exit seeking. Resident representatives reported that the resident had “bounced back” after her decline, was always wandering, tried to get to doors and elevators, and had been described by staff as trying to get out of the building. These documented conditions, combined with the absence of an active monitoring device and the lack of staff awareness of her departure from the unit and building, led to the neglect finding related to elopement.
Removal Plan
- Returned Resident #5 to the facility.
- Completed a skin assessment, pain assessment, and change of condition assessment for Resident #5 with no negative findings.
- Notified Resident #5’s attending physician and obtained new orders for labs; obtained urine culture results showing ESBL and implemented new medication orders.
- Completed psychiatric services via telehealth for Resident #5 with no new orders received.
- Placed Resident #5 on 1:1 supervision and completed an elopement assessment with an electronic monitoring device applied to her lower extremity; maintained 1:1 supervision until discharge.
- Checked electronic monitoring device function and placement for all current residents at risk for elopement with no negative findings.
- Verified all residents’ demographics were in each resident elopement binder at the nurse station, receptionist area, and therapy gym.
- Added Resident #5’s demographics and picture to the elopement binder.
- Completed door checks to ensure all doors worked properly with no negative findings.
- Completed a 100% head count to ensure all residents were in the facility with no negative findings.
- Re-assessed 100% of residents for elopement risk with no new residents identified.
- Completed an elopement drill; reviewed and documented results on the Elopement Drill QAPI worksheet with no negative findings.
- Gathered witness statements from residents and staff.
- Notified DCF and police of an allegation of neglect.
- Arranged for psychiatric services evaluation for Resident #5.
- Discharged Resident #5 to a memory care unit as planned with the IDT, family, and Medical Director.
- Placed a door guard to ensure no one was able to leave the facility until screamers were installed.
- Completed elopement drills every day, three times per day, randomly.
- Completed elopement drills once per week on random days.
- Completed monthly elopement drills on random shifts and days, with results reviewed with the QAPI team.
- Verified screamers were shipped from the manufacturing company.
- Installed cameras and new secure care boxes.
- Completed door checks to ensure doors were functioning properly.
- Met with the IDT and Clinical Consultant to discuss removal of the door guard and removed it.
- Assessed for a possible amber alarm system and installed the system.
- Set up security cameras in the facility with the main station located in the NHA office.
- Held IDT meetings (including the Medical Director) to review the ad hoc/QAPI plan; the Medical Director reviewed and recommended no changes.
- Provided education to 100% of staff (including contract employees) regarding abuse/neglect, missing persons policy, elopement policy (including care plans and Kardex for those at risk), and staff response to door alarms.
- Initiated elopement drills for 100% of staff (including contracted employees).
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
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