Failure to Supervise Cognitively Impaired Resident Resulting in Unnoticed Elopement
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment to prevent unsafe wandering and elopement for a cognitively impaired resident. The resident was admitted with diagnoses including esophageal cancer, severe protein‑calorie malnutrition, adult failure to thrive, and a history of immunosuppression therapy. Therapy and clinical evaluations shortly after admission documented moderate cognitive impairment, decreased insight, poor judgment, and decreased safety awareness. A Speech Language Pathology evaluation showed moderate cognitive‑communication deficits with impaired short‑term memory, problem solving, and executive functioning, and a SLUMS score indicating moderate cognitive impairment. The admission MDS BIMS score also indicated moderate cognitive impairment, and the care plan identified cognitive loss/dementia and fall risk. Multiple nursing and provider notes over the following weeks documented intermittent and worsening confusion, treatment‑interfering behaviors such as repeatedly pulling out IV/PICC lines, disorientation, and statements reflecting confusion. Despite this documentation, the facility’s Elopement Risk Evaluation completed on 11/6/25 concluded the resident was not at risk for elopement. The Unit Manager who completed the tool answered “No” to questions about cognitive impairment, poor decision‑making, exit‑seeking behaviors, wandering oblivious to safety, and history of elopement, while acknowledging the resident was independently mobile and able to exit the facility. On 11/19/25, a psychiatric APRN formally evaluated the resident for capacity at the request of the primary physician and documented that the resident lacked capacity to make decisions related to healthcare or long‑term placement, was significantly disoriented, and could benefit from a guardian or POA. Another APRN note the same day described significant disorientation and fluctuating mental status, with risk of delirium and unsafe behaviors. Nonetheless, the facility did not update the elopement risk assessment or care plan to reflect this change in condition and did not implement elopement‑specific interventions. On the day of the incident, staff notes and the facility’s own timeline show that the resident was last seen at the nursing station around mid‑morning, when he denied needing anything. The front desk receptionist left the front desk unattended to go to the kitchen, and the front door, which could be opened without staff intervention, was left accessible. Around that time, EMS exited the building with another resident, and the facility asserts the doors closed and locked, but the receptionist later stated that a visitor likely opened the front door, allowing the cognitively impaired resident to leave unnoticed. The resident walked out the front door, crossed a two‑lane road, and traveled approximately half a mile over uneven terrain and near multiple water retention ponds to a nearby college dormitory. College staff found him in the dorm, describing him as confused, disoriented, unsteady, shaking, disheveled, and unsure of where he was. EMS documentation noted he did not remember where he was supposed to be and believed he was in a different city. The facility did not become aware that the resident had left until contacted by campus security after EMS had been called, and there was no documentation in the clinical record that the resident had exited the facility without staff knowledge or supervision. Interviews with the Unit Manager indicated she was told not to document the incident and that no elopement re‑evaluation or care plan update was completed afterward. The facility’s failure to recognize and act on the resident’s documented cognitive impairment and lack of capacity, to accurately assess elopement risk, to maintain supervision at the front entrance, and to document the elopement led to the determination of Immediate Jeopardy under F689. The resident’s family member reported being very upset that they were not notified of the incident until 24 hours later and expressed concern about what could have happened while the resident was unsupervised outside the facility. The Administrator and DON acknowledged in interviews that the resident left the facility without staff knowledge and supervision, but the Administrator repeatedly resisted characterizing the event as an elopement, instead describing it as the resident going for a walk and forgetting to sign out. The Administrator also stated that she would allow residents she considered cognitively impaired but without a formal incapacity statement to leave unsupervised and was unaware of the psychiatric APRN’s documented incapacity determination at the time. The DON confirmed that she did not direct staff to make a late entry documenting the incident and did not order a new elopement risk assessment, stating she believed the resident was alert and oriented and that a new evaluation was only done when a resident newly expressed a desire to leave and “did not make sense.” These actions and inactions, in the context of extensive documentation of confusion and impaired safety awareness, contributed directly to the unsafe elopement and the cited deficiency for failure to prevent accidents and provide adequate supervision.
Removal Plan
- Resident #900 no longer resides at the facility and was successfully discharged home as planned.
- Resident #900 was immediately placed on 1:1 staff observation.
- A licensed nurse performed a complete skin inspection for Resident #900 with no new skin concerns identified.
- Resident #900’s cognitive status was re-evaluated using the BIMS assessment.
- The Administrator/Designee re-educated all staff on Missing Resident Drill and Elopement policy, emphasizing responding to door alarms, using the elopement binder, performing a resident headcount, and Administrator/DON notification.
- The Administrator modified the receptionist process for residents exiting the facility and added it to new hire education, including use of a binder with blue (requires supervision) and white (safe for unsupervised LOA) sheets, clinical team determination of supervision, and resident sign-in/sign-out for each LOA; front door opened by remote or keypad.
- The contracted vendor removed the automatic open option on the front double doors so doors remain locked with access by staff remote or keypad entry/exit only.
- The facility extended receptionist hours to 7:00 a.m.–9:00 p.m., 7 days/week.
- The front desk coverage process was updated to establish coverage when the receptionist is on break/steps away and to define the process for 9:00 p.m.–7:00 a.m. for assisting residents with LOA and/or visitors entering/exiting.
- Residents admitted in the last 30 days were re-evaluated for accuracy of new admission assessments and documentation related to cognitive status and elopement risk by the DON/Designee.
- The Administrator confirmed the LOA process is included in the new admission packet.
- The DON/Designee completed a new elopement risk assessment on all current residents in the electronic medical record system.
- The receptionist on duty for the event was re-educated on ensuring residents exiting the facility were approved by clinical staff prior to exit and on the binder/blue-white sheet LOA process and door access process.
- The DON/Designee re-educated all employees on F689 (including CMS definition of elopement), the updated facility elopement policy, documentation of resident incidents in the clinical record, and the new receptionist process for resident exiting (binder/blue-white sheets, clinical team determination, sign-in/sign-out, remote/keypad door access).
- All licensed nurses were educated on communicating physician changes to a resident’s capacity and notifying the DON and/or Administrator at the time of determination to ensure timely re-evaluation of elopement risk.
- An ad hoc QA meeting was held with the facility Medical Director in attendance via phone.
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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