Failure to Respond to Exit Alarm and Supervise High-Risk Resident Resulting in Elopement and Injury
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from neglect by not responding appropriately to an exit door alarm and not providing adequate supervision to prevent elopement. The resident had diagnoses including dementia, psychotic disorder with hallucinations, depression, delusional disorder, falls, muscle weakness, and lack of coordination. A recent MDS showed a BIMS score of 6, indicating severe cognitive impairment, and progress notes documented wandering, impulsivity, agitation, difficulty with redirection, and concern for safety. The resident had been assessed as at risk for elopement, with an elopement risk score of 19 on admission (≥12 indicating risk) and a subsequent score of 10, and the care plan identified elopement risk related to cognitive impairment with interventions such as notifying other departments of elopement risk and using verbal cues and distraction techniques. On the night of the incident, the resident was last seen by the assigned CNA around 2:30 a.m. in bed asleep. Shortly thereafter, an emergency stairwell exit door alarm by the therapy department sounded. Video footage later reviewed by the Director of Plant Operations showed the resident, without a walker or wheelchair, walking down the therapy hallway holding the railing, leaning on the stairwell door at approximately 2:32 a.m., triggering the alarm and the audible message “Exit now, exit now,” and then opening and closing the door. The resident then descended two flights of stairs and exited the building through another alarmed door to the outside, all unwitnessed by staff. The stairwell and exterior areas had no cameras, and no staff were observed responding to the alarm during at least 20 minutes of reviewed footage. Multiple staff heard or were informed of the alarm but did not initiate the facility’s elopement procedures. The supervising LPN on duty, who was on the second floor when the alarm first sounded, attempted to silence the alarm but could not recall the code and assumed the alarm was malfunctioning. She contacted maintenance for assistance and then returned to other tasks on the first floor without initiating a search, checking outside, or calling a code for a head count. The assigned CNA was on break when the alarm sounded, received a call from the supervisor about the alarm, and believed it was another malfunction similar to a prior event; he did not check on his residents when he returned from break and recalled the alarm still sounding. The LPN assigned to the resident heard an unfamiliar alarm but did not recognize its source, did not immediately verify resident whereabouts, and reported not having been trained on elopement drills or the sound of the door alarms. Other staff on the first floor either did not hear the alarm or were told by the supervisor that it was a malfunction. During this time, the resident left the facility, walked through the parking lot, crossed a four-lane road, and entered a neighborhood where he fell, sustaining a left forehead laceration and left elbow skin tear, and was eventually found outside, wet and shivering in the rain, by local law enforcement and transported to the hospital. The facility did not become aware of the resident’s absence until notified by law enforcement, and the resident had been missing for approximately two hours without staff knowledge, leading surveyors to determine Immediate Jeopardy related to neglect and failure to prevent elopement. Interviews with clinical providers further underscored the resident’s known risks. The nurse practitioner and physician described the resident as having advanced dementia, confusion, cognitive dysfunction, impulsivity, restlessness, difficulty with redirection, shuffling gait, and muscle weakness, with a history of expressing a desire to go home and requiring assistance with ambulation using a walker. Staff nurses and CNAs reported that the resident frequently wandered, was extremely confused, constantly tried to get up, was unsteady on his feet, and required frequent redirection, with some staff stating he should have been on 1:1 supervision or 15-minute checks due to his behaviors and fall risk. Despite these known risks and the existing care plan identifying elopement risk, staff did not implement effective supervision or appropriate responses to the door alarm on the night of the incident, resulting in the resident’s unwitnessed elopement and injury.
Removal Plan
- Implemented 1:1 supervision with staff at all times for Resident #2 due to elopement risk.
- Implemented an order that Resident #2 may only go out on leave of absence (LOA) with a responsible party.
- Updated Resident #2 care plan to include family assisting with placement to a secured unit.
- Updated Resident #2 care plan to include providing the resident with a 1:1 companion as needed to decrease risk of exit seeking.
- Provided education to the assigned nursing supervisor and assigned nurse regarding responding to alarming doors, searching immediate surroundings, completing a head count when doors alarm, and timely DON notification of elopement.
- Suspended the nurse supervisor and assigned CNA pending investigation.
- Held an ad hoc QA meeting regarding elopement with the Administrator, DON, ADON, VP of Clinical Operations, and Medical Director.
- Conducted ongoing QAPI discussions focused on response to alarming doors, elopement drills, head counts, and prevention of neglect related to elopement.
- Provided education to the DON, ADON, and Administrator regarding the elopement, affected policies, alarming doors, head counts, risk management reports, reporting to AHCA, elopement drills/audits, QAPI, hourly head count, investigation guidance, and ongoing education/monitoring.
- In-serviced department heads on responding to alarming doors and checking surrounding areas to visually ensure the area is secure.
- Initiated abuse and neglect policy education with all current staff, emphasizing neglect, maintaining a safe environment, and required actions when a door alarm sounds.
- In-serviced assigned staff on responding to alarming doors, checking surrounding areas, performing a head count, and neglect/elopement prevention and response.
- Conducted elopement drills on every shift, then implemented random weekly drills performed by DON/ADON/designee.
- Started elopement education audits, then transitioned to random-shift audits performed by DON/ADON/designee.
- Completed elopement risk reassessments for all residents by ADON, clinical unit managers, and DON.
- Reviewed care plans for residents at risk for elopement by DON.
- Reviewed the elopement binder for accuracy by DON.
- Audited all current residents' LOA orders in the electronic health system by DON, ADON, and unit managers.
- Performed routine door monitor/alarm function checks at all exit doors by the Director of Maintenance.
- Tested exit alarms by a third-party independent contractor.
- Updated the CE-4 Elopement Prevention Policy; reviewed with the IDT in ad hoc QAPI and re-issued to all departments with education provisions.
- In-serviced current staff on the updated CE-4 Elopement Prevention Policy.
- Implemented emergency in-servicing education that all alarming doors must be treated as potential resident elopement and require a head count, and that only maintenance can identify a malfunctioning door alarm.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to protect two residents with severe cognitive impairment from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent after repeated sexual encounters were discovered. Staff found the residents together in bed or in the bathroom, often unclothed, and allowed privacy based on their behavior without documenting a structured consent assessment. The facility also did not fully investigate unexplained bruising and reported vaginal bleeding for one resident in the setting of the known relationship, and the MD was not notified of the incidents or injuries.
Failure to protect a resident from resident-to-resident physical abuse: one resident entered another resident’s area, got into her belongings, and then grabbed, hit, and scratched her left wrist/hand, causing a skin tear, bruise, swelling, and pain. The injured resident said she was afraid of the other resident, while staff heard yelling, found both residents in the room, separated them, and documented the wound and bruising. The other resident had dementia with behavioral disturbance and used a walker and wheelchair.
Failure to protect a resident from resident-to-resident abuse: a resident with PTSD and a long history of physical and sexual abuse reported another resident repeatedly entered their room at night, then later exposed himself, blocked the resident from leaving, and used meth in front of them. The record lacked an investigation, trauma assessment, psychosocial monitoring, and documented behavior-based monitoring for the other resident, and staff interviews confirmed the concerns were not fully addressed in the chart.
A resident with dementia, CKD, HF, and severe cognitive impairment was involved in a physical abuse allegation when a CNA struck or batted his arm/hand during care after he grabbed at staff. A witness reported that the CNA hit the resident hard and yelled at him, while the CNA said she only tapped his hand away and did not consider it abusive. The resident could not answer questions about the event, and the facility’s records showed the allegation was not promptly escalated through the abuse reporting chain.
A resident with impaired cognition, stroke-related deficits, and constipation was subjected to manual stool removal by an LPN after a suppository did not work. Staff interviews and the resident’s statements indicated she said stop and begged the LPN to stop while he continued the procedure, and she later described the care as painful, violating, and demeaning. The LPN said he manually removed the stool in the bathroom, did not complete an abdominal assessment, and did not contact the provider for further direction.
A resident with CKD, CHF, ESRD, DM, and multiple foot wounds did not receive ordered daily wound care, and the TAR and progress notes lacked documentation that the treatments were completed on multiple occasions. The resident was later hospitalized for worsening wound infection, with purulent drainage and concern for osteomyelitis; the wound care provider also reported concerns that ordered dressing changes were not being done and noted worsening skin breakdown to the buttocks.
Failure to Assess Consent and Investigate Injury With Resident Sexual Activity
Penalty
Summary
The facility failed to protect two cognitively impaired residents from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent to sexual activity after becoming aware that they were engaging in sexual contact. One resident had diagnoses including Alzheimer’s disease, neurocognitive disorder with Lewy bodies, dementia, and anxiety, with documentation showing severe cognitive impairment, wandering, hallucinations, confusion, and inability to consistently orient to time or place. The other resident also had diagnoses including Alzheimer’s disease and dementia with psychotic disturbance, with repeated BIMS scores showing severe cognitive impairment and care plan documentation noting cognitive loss and a history of wandering and checking doors. The record showed repeated incidents in which the two residents were found together in bed or in the bathroom, often unclothed, and staff documented that they appeared calm or did not show obvious distress. Staff notes and interviews showed that the residents were allowed privacy and continued access to each other without documentation of a formal assessment of whether either resident understood the nature of the relationship or could knowingly and voluntarily consent. Staff interviews also reflected that they relied on the residents’ behavior, such as whether they pushed away or said no, rather than documenting a structured assessment of capacity after each incident. The facility also failed to investigate unexplained bruising and reported vaginal bleeding for one resident in the context of the known sexual activity. The record documented bruises on the forearms and thigh in various stages of healing, along with a report of bloody vaginal discharge, but there was no evidence of a physical assessment or investigation to determine whether the findings were related to abuse, coercion, trauma, or another cause. Interviews with the RN, LPN, DON, MD, and family showed that the physician had not been notified of the sexual incidents, the bruising, or the vaginal bleeding, and that staff had not documented a formal assessment after the incidents.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident physical abuse when one resident attacked another during the night, causing a skin tear to the left wrist, bruising to the left thumb, swelling, pain, and fear for safety. The injured resident was admitted with diagnoses including type 2 diabetes mellitus, unsteadiness on feet, need for assistance with personal care, and muscle weakness, and had a BIMS score of 15/15 indicating cognitive intactness. The other resident involved had diagnoses including type 2 diabetes mellitus, dementia with other behavioral disturbance, and essential hypertension, and used a walker and wheelchair for locomotion. According to the injured resident, she returned from the bathroom and found the other resident in her area getting into her refrigerator. When she told the other resident to get out of her things, the other resident became angry, grabbed her left wrist, hit her left hand, and scratched her, causing the injury. The injured resident stated she was afraid of the other resident and was glad the other resident had been moved to another unit so she could not hurt her again. At observation the next day, the resident’s left wrist/hand was bandaged, an observable bruise was present at the base of the left thumb, and the hand/wrist was slightly swollen and painful to touch. Facility documentation and staff statements confirmed that staff heard yelling from the room, found the residents in the room, and separated them. Nursing notes documented a skin tear with partial skin flap loss to the left wrist/forearm and bruising to the left thumb, with the wound cleansed and steri-strips applied. Staff statements described the other resident as being in the injured resident’s area and making unwanted contact, while the administrator stated the investigation was still ongoing and could not yet determine whether resident-to-resident abuse had occurred. The facility’s abuse prevention policy states residents are to be free from abuse by anyone, including other residents, and defines physical abuse as willful infliction of injury resulting in physical harm or pain.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse and failed to provide adequate supervision and effective interventions when Resident 7 reported fear and unsafe interactions with another resident. Resident 7 was admitted with COPD and PTSD and had a documented history of childhood through adulthood abuse, including physical and sexual abuse, domestic violence, and trafficking. A trauma questionnaire showed Resident 7 had previously tried to avoid reminders of past events and reported that nothing made them feel worse at that time. In one incident, Resident 7 told staff they were afraid to go to sleep because another resident came to their room at night and shook them awake. The resident admitted going to the room and waking Resident 7, and staff educated that resident about safety and respect. The progress note did not appear in the incident log or grievance log, and the record did not show an investigation, monitoring for negative psychological social outcomes, a trauma assessment, or care plan interventions to promote a sense of security. Staff interviews confirmed the social service department was unaware of the situation and that a trauma assessment should have been completed. In a second incident, Resident 7 reported that the same resident blew methamphetamine smoke in their face in the smoking shed, blocked them from leaving with a wheelchair, and exposed and masturbated in front of them. Resident 7 stated the event triggered past childhood trauma and made them feel trapped. The facility investigation documented a separation plan and one-to-one supervision for Resident 7, while the other resident was placed on alert status with increased monitoring and behavior risk. However, the record did not show implementation of behavior-based monitoring for the other resident, and observations later showed Resident 7 without staff supervision.
Physical abuse allegation involving a resident during care
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse when a CNA slapped the resident’s arm during care. The resident was a male with dementia without behavioral disturbance, chronic kidney disease, and heart failure. His care plan identified that he could be physically aggressive due to poor impulse control and resistive to care because of impaired cognition, and his quarterly MDS showed severely impaired cognition with a BIMS score of 2, extensive assistance needs for most ADLs, and bowel and bladder incontinence. According to the incident documentation, the event occurred in the resident’s room during care when one CNA reported that another CNA hit the resident’s hand after the resident grabbed her. A written statement from the witnessing CNA said the CNA hit the resident hard on the arm and then yelled at him. The resident was unable to answer questions about the event because of his stroke and cognitive impairment, and the incident report noted that he had a history of hitting staff. The CNA involved stated that the resident struck her arm and that she tapped his hand gently, comparing her action to what one would do with a child. The facility’s investigation summary described the contact as the CNA batting the resident’s hand away, while the witness described it as striking the resident on the arm. The report also showed that the allegation was not immediately escalated through the facility’s abuse reporting process, as the witness said she reported it to an LVN and was told the DON had been notified, but the abuse coordinator did not receive the information until later. The facility’s records also reflected that the incident was ultimately treated as an unsubstantiated allegation of abuse.
Abuse During Manual Stool Removal
Penalty
Summary
The facility failed to ensure a resident was free from abuse during bowel care when an LPN performed manual removal of impacted stool from the rectum without consent and continued after the resident asked him to stop. The resident had moderately impaired cognition, was dependent on staff for transfers and toileting hygiene, and had a history of constipation. Her diagnoses included stroke, atrial fibrillation, hemiplegia/hemiparesis, adjustment disorder, and mixed anxiety and depressed mood. Her care plan identified limited physical mobility and the need for two staff with a stand lift for transfers. On the day of the incident, the resident had not had a bowel movement for several days and had received constipation medications and a rectal suppository. Progress notes documented that a rectal check found hard stool and that manual evacuation was performed with removal of large amounts of stool. Staff interviews described that the resident cried, said stop, and begged the LPN to stop while he continued the manual removal for additional time. The resident later reported that the procedure was painful, that she felt violated, embarrassed, and demeaned, and that she believed the nurse was smiling and laughing at her during the care. Multiple staff interviews confirmed that the resident was distressed during the procedure and that the LPN did not stop when she requested it. Staff also stated the procedure was invasive and should have been stopped when the resident expressed pain. The LPN stated he manually removed the stool in the bathroom, did not complete an abdominal assessment, did not administer an enema before manual removal, and did not contact the provider for further direction. The report also states the facility failed to ensure the resident was free from abuse during cares, and the immediate jeopardy was identified based on this event.
Failure to Complete Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care services as ordered by the physician for one resident with multiple chronic conditions, including CKD, CHF, HTN, ESRD, muscle wasting/atrophy, anemia, and diabetes-related foot wounds. The resident’s records showed a BIMS score of 15, indicating cognitive intactness, and documented multiple wounds, including ulcers on both feet, a diabetic foot ulcer, and a wound infection. Physician orders required daily wound care to the left calcaneus, right calcaneus, right plantar foot, right medial foot, and daily povidone-iodine application to the right foot, but the TAR did not document completion of these treatments on multiple dates in May 2026, and the progress notes also lacked documentation that the treatments were completed. The resident was hospitalized on 5/26/26 with worsening wound infection. The hospital history and physical documented ESRD on daily dialysis, CHF, COPD, DM, depression, HTN, prior MI with stenting, oxygen use, chronic wound status, and ulcers of both feet with necrosis of muscle. The hospital record stated the resident reported the nursing home should have been changing wound dressings daily but said that was not done. The wound care provider stated the right foot wound had purulent drainage, she was concerned about osteomyelitis, and she sent the resident to the emergency room. She also stated she had concerns that the facility was not completing the ordered dressing changes and that the resident had worsening buttocks skin breakdown, while the DON stated treatments should be completed as ordered and documented on the TAR or in progress notes.
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