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:
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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