F0689

D

Failure to Prevent Fall and Elopement for High-Risk Residents

Marion, Ohio Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for two residents. For one resident with diagnoses including congestive heart failure, COPD, obesity, depression, diabetes type 2, and anxiety, the quarterly MDS showed intact cognition, a need for two-person assistance with ADLs, and a risk for falls. The resident’s care plan identified fall risk and included an intervention that the call light be kept within reach, wrapped around the transfer handle on the bed. After the resident experienced an unwitnessed fall in his room, the fall investigation documented that he had been found on the floor on his left side, with the bed in a raised position, and that he reported falling while reaching for his call light, which was out of reach. The DON confirmed that at the time of the fall the resident had been placed in a new bariatric bed without grab bars and that no bed rail assessment had been completed for the new bed until nearly two weeks later.

Subsequent observation showed the resident in bed with the bed elevated and the call light clipped to the bed sheet at the head of the bed, rather than wrapped around a transfer handle as care planned. The resident reported that when he first received the new bed, it did not have the two transfer bars attached for the first few days, that he had raised the bed to a high level, and that he rolled out of bed while trying to reach a call light and bedside table that were out of reach. He stated he had been educated not to raise the bed to the highest level but preferred it raised despite the fall risk, and he believed the fall was partly due to his own actions and partly due to staff not placing the call light within reach and not applying the grab bars on the new bed. An LPN stated the resident was non‑compliant with keeping the bed low, that staff had left the bed in a low position, and that the resident raised it after they left; the LPN could not recall whether the call light had been left within reach. The DON verified that the call light was not within reach at the time of the fall and that the new bed had not been assessed before use.

The deficiency also involves the facility’s failure to ensure the safety and security of a newly admitted resident with Alzheimer’s disease, dementia, diabetes, and hypertension, who resided on a secured memory care unit and was an elopement risk. On admission, an elopement assessment scored the resident as low risk, and no further elopement assessments were completed through the time of the incident. The resident’s care plan initially addressed impaired cognition and dementia but did not identify elopement risk until later; progress notes documented that the resident’s daughter/POA requested removal of the resident’s cell phone because he was calling the police and repeatedly calling about getting out of the facility. Staff interviews revealed that the resident had been observed walking the halls and pressing on locked exit doors and that he later left the locked memory care unit with a male visitor who was not an approved contact, carrying a duffle bag of belongings, after the unit manager allowed the visitor to take him to the parking lot to exchange items. CNAs and nursing staff reported that the resident did not return, that staff did not know his whereabouts for an estimated 30–60 minutes before they began searching, and that they discovered he had left the property with the visitor.

Multiple staff members, including an LPN and CNAs, stated that residents from the memory care unit should not be allowed off the unit or off the property with anyone other than the POA or approved individuals, and that staff should check the medical record to verify who is authorized to take a resident out. The LPN and CNAs considered the event an elopement because staff did not know where the resident was for a period of time and he had expressed a desire to leave. The facility’s internal timeline indicated that a friend asked to accompany the resident outside to gather laundry, that the unit manager agreed, and that the resident got into the friend’s vehicle without notifying staff. Social Services staff reported seeing the resident, known to be from the memory care unit, get into a car with a male visitor and the resident’s wife and drive out of the parking lot, but did not inform unit staff. Hospital records from that day documented that the resident was removed from a locked Alzheimer’s unit with a friend against the POA’s wishes, taken home, became increasingly agitated, and made suicidal statements, leading to his transport to the emergency department. Interviews with facility leadership confirmed that the resident was out of the facility for about 12 hours, that the elopement assessment and care plan were not updated when the resident began exhibiting behaviors such as pressing on doors, pacing the halls, and calling others to get him out, and that interventions related to elopement risk were not initiated until after the incident.