F0689

G

Failure to Supervise Resident and Address Medication Hazard Leading to Elopement and Injury

Hazleton, Pennsylvania Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure appropriate supervision and implementation of safety interventions to protect a resident from accident hazards related to medications and elopement. The resident was cognitively intact, diagnosed with insomnia and bipolar disorder, and had physician orders allowing independent ambulation in the room and on the unit, and at one point off the unit and on facility grounds with a rollator. The resident experienced multiple falls in late November and December, including a fall in another building and a fall by the sink, and was later observed with an unsteady gait. Despite these events and changes in ambulation orders, an elopement risk assessment initially identified the resident as not at risk for elopement, and the facility did not revise supervision or safety interventions in response to the resident’s changing condition and mobility status.

On December 29, the resident was found walking back from the bathroom with an unsteady gait and an oxygen saturation of 84%. The resident told staff she had taken pills but could not identify what type. She was transferred to the ED for evaluation of a possible medication overdose and received two doses of Narcan, after which she became more responsive. Upon return, trazodone was discontinued. The resident later reported that during medication administration she sometimes dropped pills on the floor or bed, kept dropped pills in her drawer, and took them later if she chose, and that pills were found on her floor around the time of the suspected overdose. The NHA and DON acknowledged that the facility did not complete an internal investigation of this potential medication overdose because the ED did not confirm an overdose, despite documentation and resident statements indicating she had consumed unknown pills.

On December 30, the resident fell from bed while reaching for the call bell and later was found on the floor in the social services office on another floor, after having positioned her walker at the office door and lying on the floor to hide from staff. Following these events, her ambulation status was changed to require assistance of one person with a rollator and independence off the unit within the building was discontinued, but the facility did not complete a new elopement risk assessment or revise supervision and safety interventions to reflect her increased need for monitoring and restricted off-unit mobility. In the early morning hours of December 31, after requesting trazodone that had been discontinued, the resident was last seen in bed around 4:30 a.m. and then independently used the elevator and exited through the unlocked front doors without a wander guard. Security camera footage showed her leaving the building, crossing the parking lot, and walking toward a gazebo in snowy, cold conditions. She fell near the gazebo, called 911 from her cell phone, and was found outside by EMS and staff with complaints of leg pain and feeling cold. Hospital imaging confirmed a left femoral neck fracture requiring surgery and a left pelvic hematoma with active extravasation. An elopement/wandering care plan and elopement risk assessment identifying potential risk and need for increased supervision were not initiated until after this elopement and injury.