Failure to Supervise High-Risk Dementia Resident Resulting in Unnoticed Elopement
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for one cognitively impaired resident who was known to be at risk for wandering. The resident had diagnoses including unspecified dementia, psychosis, depression, and anxiety, and was consistently described as alert only to self, confused at baseline, and unable to care for herself. Quarterly MDS data showed she could ambulate 150 feet with supervision or touching assistance, and therapy notes documented that she could ambulate 275 feet without an assistive device. Progress notes and staff interviews described ongoing wandering behavior throughout the unit, frequent need for redirection for safety, and episodes of verbal and physical aggression during care. The resident’s psychiatric and primary care providers, as well as her representatives, characterized her as ambulatory, severely cognitively impaired, and unable to care for herself outside the facility. Despite this history, the resident did not have an active electronic monitoring device at the time of the incident, even though prior physician orders and the active care plan documented use of such a device earlier in the year and identified her as an elopement risk. Elopement Risk Evaluations in February and May identified her as at risk, and her care plan included interventions related to elopement risk and monitoring of an electronic monitoring device. The DON later stated that the May Elopement Risk Assessment was incorrect because it was completed based on pre-hospitalization information, and the resident was not listed in the elopement binders as an elopement-risk resident on the date of the event. Facility leadership and nursing staff reported that when the resident returned from the hospital she was initially not an elopement risk due to being unable to get out of bed, and that when she later regained mobility and began walking well again, an electronic monitoring device was not reapplied because she was not considered exit seeking. On the day of the incident, the resident was observed by staff on the fourth floor earlier in the shift, wandering as usual, and was redirected to her room. Approximately 10–15 minutes later, staff became aware that a door alarm was sounding from a stairwell exit on the west side or backside of the building, but they did not initially know why the alarm was going off or whether a resident had gone out. During this time, another cognitively intact resident, who was outside on a leave of absence, saw the confused resident walking around the west side of the building near generators, wearing a hospital gown and blanket, and appearing headed somewhere. He approached her, noted her confusion, and directed her to sit on a bench in front of the building, where a staff member saw them and helped bring her back inside. Staff interviews and the facility’s own investigation confirmed that no staff member observed the resident leaving the fourth floor, using the elevator or stairs, or exiting the building, and that staff did not know she had left the unit until she was brought to the front entrance by the other resident. The facility determined that she had exited through a stairwell door that should have been locked and that the alarm associated with that door could only be heard in or just outside the stairwell, not at the front reception area. This sequence of events, combined with the lack of an active electronic monitoring device and failure to recognize and manage her ongoing elopement risk, led to the resident’s unsupervised exit from the building and the determination of Immediate Jeopardy. Resident representatives reported that the resident had "bounced back" and was up and moving weeks after her May hospitalization, and that she was always wandering, trying to escape, and attempting to get to doors and elevators. They stated that staff had told them multiple times that she tried to get out of the building and that she wandered in and out of other residents’ rooms, taking items. Clinical staff, including the OT, PMHNP, ARNP, and PCP, consistently described her as ambulatory, oriented only to person, confused, easily redirected, and not capable of caring for herself outside the facility, with some specifically stating they considered her an elopement risk. Nonetheless, she was not being monitored with an electronic device at the time of the event, and staff on the unit were unaware she had left the floor until after she had already been outside and was returned by another resident. These actions and inactions regarding risk assessment, care planning, and supervision directly contributed to the elopement event that formed the basis of the cited deficiency and Immediate Jeopardy determination.
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, completed an elopement assessment, and applied a wanderguard to her lower extremity; maintained 1:1 supervision until discharge.
- Completed wanderguard function and placement checks for all current residents at risk for elopement with no negative findings.
- Confirmed all residents’ demographics were included 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 and 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.
- Ensured Resident #5 was evaluated by psychiatric services and confirmed no injuries or complaints related to the event.
- Discharged Resident #5 to a memory care unit as planned with the IDT, family, and Medical Director.
- Placed a door guard at the door to ensure no one was able to leave the facility until additional alarm measures were installed.
- Completed elopement drills multiple times per day on random schedules.
- Completed weekly elopement drills on random days.
- Completed monthly elopement drills on random shifts and days and reviewed results with the QAPI team.
- Verified shipment of screamers 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 reached agreement.
- Completed a security company assessment 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 to review the ad hoc/QAPI plan with no negative findings and obtained Medical Director review with no recommended changes.
- Provided education to 100% of staff (including contract employees) related to abuse and neglect, missing persons policy, elopement policy (including care plans and KARDEX for those at risk for wandering/elopement), 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:
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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