Failure to Prevent Elopement and Account for Cognitively Impaired Resident After Door Alarm
Summary
The deficiency involves the facility’s failure to prevent the elopement of a cognitively impaired resident and to ensure that all residents were accounted for after a door alarm sounded. The resident had multiple diagnoses including dementia, altered mental status, anxiety disorder, unsteadiness on feet, malnutrition, alcohol abuse, pulmonary fibrosis, and a left femur fracture. An elopement risk assessment identified the resident as high risk for elopement, and the Minimum Data Set documented that the resident was not cognitively intact. CNA documentation on two dates in January showed elopement behaviors, and a nurse practitioner documented severe cognitive impairment and disorientation in late January and early February. The resident’s care plan noted cognitive impairment and multiple fall and safety risk factors, including poor safety awareness and dementia. Despite this, the resident’s picture was not included in the facility’s “Walkers” binder used to identify residents who wander. On the night of the incident, staff reported that the resident was last seen in bed asleep between approximately 3:45 AM and 4:00 AM. The RN on duty stated that the main exit door alarm sounded around 3:00–3:20 AM; she turned off the alarm, looked outside, and did not see anyone, but did not notify the nursing supervisor on other units. She reported that a resident head count was performed after the alarm, but this was not communicated consistently, as the nursing supervisor stated she was never notified of an alarm and did not perform a head count on her units. Another CNA gave conflicting statements about whether she recalled an alarm and whether a head count was done, but confirmed that she believed all residents were present at that time. The facility’s policy on elopement and wandering residents states that alarms are not a replacement for necessary supervision, that staff must respond to alarms in a timely manner, and that a systematic approach to monitoring and managing residents at risk for elopement is required. At approximately 5:42–5:43 AM, police responded to a 911 call from a passerby reporting a person in a wheelchair sitting outside in the cold. The police officer found the resident about a block away from the facility, in a wheelchair, wearing only a thin sweater with no winter gear, with a sweater on the ground nearby. The officer observed that the resident was very cold, shivering, had a shaky voice, smelled strongly of urine, and had wet pants in the groin area. The resident was disoriented, did not know where she lived or where she was going, and stated she had been outside all night. EMS arrived and documented cold exposure, chills, confusion, and cold skin, with an impression of hypothermia and emergent acuity. The resident was transported to the emergency department, where she was monitored and later documented to have a rectal temperature of 95.9°F at discharge. The police officer subsequently went to the facility and learned from staff that they had not known the resident had left the building until he informed them. He also reported that staff told him an exit door alarm had gone off around 3:30 AM but they were unable to confirm the cause, and he later observed wheelchair tracks in the snow near an employee exit door with an unshoveled sidewalk, suggesting a potential route of exit. These events demonstrate that the facility did not ensure adequate supervision and monitoring of a known high elopement-risk, cognitively impaired resident and did not effectively account for all residents after a door alarm sounded, resulting in the resident’s elopement and exposure to cold. The Immediate Jeopardy was determined to have begun when the resident was found outside in the cold in her wheelchair by herself and was transferred to the hospital for cold exposure. The administrator was notified of the Immediate Jeopardy several days later. Interviews with nursing staff, the nursing supervisor, the police officer, and the resident, along with review of clinical records, EMS and hospital documentation, and facility policies, confirmed that the facility failed to follow its own elopement and wandering policy, failed to ensure that a high-risk resident was properly identified in the wandering binder, and failed to ensure that all residents were accounted for when an exit door alarm sounded. These failures led directly to the resident’s unsupervised exit from the facility and subsequent cold exposure. The sidewalk route the resident likely used included broken and uneven concrete and led around the facility to a shopping plaza parking lot. The police officer believed the resident left near the employee exit door because the sidewalk there was not shoveled and he observed wheelchair markings in the snow. The resident later told EMS that she had been outside all night and had been living outside for a couple of months, although she had in fact been residing in the facility. When interviewed by the surveyor, the resident could not recall going outside in the cold or speaking with a police officer, and inaccurately reported that she went out the front door to smoke a couple of times a day, despite not having smoked since admission. These observations further illustrate the resident’s cognitive impairment and confusion at the time of the elopement and underscore the facility’s failure to provide adequate supervision and monitoring for a resident known to be at high risk for elopement.
Removal Plan
- All residents were reassessed for elopement risk.
- All residents identified as high risk for elopement had care plans reviewed for accuracy.
- Elopement binder reviewed and updated to reflect high risk residents.
- An emergency QAPI was held to review policies/procedures.
- Daily door alarm audits began.
- Door alarm added to interior door leading to staff entrance.
- Second door alarms added to reception door as well as the exit between two units in order to double alarm all exits.
- Additional speakers added so alarms are more audible.
- In-Service/Education was initiated on the facility's door alarm protocol, responding to alarms, and completing head counts.
- R1 was moved to a secured unit.
- The Administrator or designee will perform elopement risk assessment audits to ensure compliance with transfer protocols; findings will be reviewed during Quality Assurance and Performance Improvement meetings monthly; noncompliance will result in immediate corrective action and additional staff training; monitoring will continue until the QAPI committee determines sustained compliance has been achieved.
- The Administrator or designee will perform door alarm response audits to ensure compliance with transfer protocols; findings will be reviewed during Quality Assurance and Performance Improvement meetings monthly; noncompliance will result in immediate corrective action and additional staff training; monitoring will continue until the QAPI committee determines sustained compliance has been achieved.
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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