Elopement of High-Risk Resident and Mechanical Lift Sling Failures During Transfers
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident identified as high risk for wandering and elopement, and the failure to ensure mechanical lift equipment and slings were in proper working order during transfers, resulting in two separate resident falls. One resident with severe cognitive impairment, dementia, poor decision-making skills, and a history of wandering and exit-seeking behaviors eloped from the building without staff awareness. This resident had a wander management system in place and was care planned and assessed as at risk for elopement. On the day of the incident, door alarms sounded and staff performed head counts on the halls, but they did not identify that this resident was missing. Staff statements indicate that alarms sounded, staff checked their assigned halls, and all residents on those halls were believed to be present, yet the eloping resident was not accounted for. The facility later learned of the elopement only after being contacted by staff from a nearby assisted living facility, who had been alerted by a community member who found the resident wandering in a ditch and then observed her walking down the road, confused and unable to state her name. Multiple interviews and written statements describe confusion among staff and residents about how the elopement occurred and how long the resident had been outside. A CNA reported taking two residents out for a smoke break and later learning from those residents that the eloping resident had been pushing on their wheelchairs trying to get out the door and that she had gotten out. Another resident reported that the eloping resident tried to push her and another resident toward the door and that she notified a nurse, who removed the eloping resident from the area; this resident later saw the eloping resident come through the door to the outside but did not see her afterward. A different resident recalled the eloping resident trying to push her and another resident to get outside and stated she went to get the nurse because the eloping resident was not supposed to go out without staff. Nursing staff, including the former ADON and an LPN, described hearing door alarms, going to the front desk, and conducting head counts when the cause of the alarm was not witnessed, but they did not determine who had set off the alarm and believed all residents were present. The facility’s own investigation notes reference a family member of another resident who knew the patio door code and used it to take her husband outside, and who was unsure whether the eloping resident may have followed her out, while also noting that this family member had memory loss and became more confused throughout the day. The second part of the deficiency concerns two separate incidents in which mechanical lift slings failed during transfers, causing residents to fall. One resident with paraplegia due to spina bifida, scoliosis, morbid obesity, and neurogenic bladder required total assist with a mechanical lift for transfers and was cognitively intact. This resident reported that during a transfer from a shower chair to bed, while suspended in the air by the lift, the sling straps broke and she fell, striking her face on the base of the lift. Progress notes and hospital records document that staff found her on the floor with her legs partially under the bed and the sling snapped and hanging from the lift, with a large amount of blood from a facial laceration, bruising and swelling around the right eye, and subsequent diagnosis of an acute nondisplaced fracture of the anterior right iliac wing. CNAs involved in the transfer stated that the sling was already under the resident, they did not inspect or test the straps before use, and that the sling loops or stitching came undone while the resident was in the air, causing her to fall. Another resident, severely cognitively impaired and dependent on staff for transfers, experienced a similar sling failure during a transfer from bed to wheelchair. Progress notes and a CNA witness statement describe that the resident was in a sling that appeared properly fitted, with straps and hooks intact and without noted fraying or breaks, when two of the sling straps on one side snapped as the resident was being lowered into the wheelchair, causing the resident to fall backward to the floor. The nurse assisting with the transfer eased the resident to the floor, and the resident sustained three skin tears to the left arm, discoloration, and a red spot on the left cheek from contact with the nurse’s knee. Staff interviews confirm that this earlier sling break occurred and that the same type of equipment was involved. The laundry supervisor stated that laundry staff were supposed to inspect every sling, discard damaged ones, and document inspections, but acknowledged that they were not documenting in the log as required and that she had been written up for this. The administrator confirmed that after the first sling-related fall, management checked with laundry about inspecting slings and not using bleach, and that after the second fall, staff were re-educated, indicating that prior to these incidents, sling inspection and maintenance practices were not being reliably documented or verified.
Removal Plan
- Resident returned to facility safely; skin assessment and vital signs completed upon return
- Resident placed on checks
- Wander management system checked for proper functioning
- Code to patio door changed
- All door alarms checked for proper functioning
- Staff education/in-service regarding elopement policy (resident supervision, redirecting exit-seeking residents, alarm response, and no sharing of door codes with non-staff members)
- DON/ADON to audit wander management system documentation on MAR/TAR
- Review and update care plans for residents at risk for elopement as needed
- Social Service Director to review the Code Yellow book to ensure completeness
- Code Yellow drills performed on each shift
- Administrator to review audits to ensure compliance
- Report trends to the QA committee and implement further corrective action as needed
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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