F0689

J

Elopement of High-Risk Resident and Mechanical Lift Sling Failures During Transfers

Taylorville, Illinois Survey Completed on 01-30-2026

Penalty

No penalty information released

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