Repeated Elopements and Self-Harm Due to Ineffective Supervision and Follow-Up
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement and self-harm for a resident identified as high risk for wandering and elopement. The resident was cognitively intact on admission, with a BIMS score of 14, but had diagnoses including Huntington’s Disease, anxiety, depression, delusions, and hallucinations, and a history of falls prior to admission. The admission assessment documented that the resident wandered one to three days per week and that this wandering placed them at significant risk of getting to a potentially dangerous place. A care plan dated at admission identified the resident as at risk for elopement and wandering related to hallucinations, with interventions focused on distraction, identifying wandering patterns, monitoring for fatigue and weight loss, and providing structured activities and reorientation strategies. A wandering risk evaluation completed shortly after admission scored the resident at high risk for wandering. Despite this, the resident repeatedly eloped from the facility. On one occasion in October, the resident left the facility without notice, crossed the parking lot, and fell in an adjacent field before being returned with assistance from local authorities; the facility’s intervention was to initiate visual checks every 15 minutes. In early November, staff documented escalating psychotic behavior, including the resident talking to themselves, insisting on contacting the FBI, and making threats toward staff and other residents. During this episode, the resident pulled a phone line from the wall and then ran out the front door, leading staff to call 911 and local authorities to locate the resident at a hotel. The facility later documented that the resident was involuntarily admitted to a hospital for psychiatric evaluation and treatment and subsequently returned to the facility. Following the resident’s return, elopements continued. In mid-January, staff were unable to locate the resident in the facility; family located and returned the resident, and documentation showed the resident had intentionally burned the back of their hand with a cigarette lighter while away because they did not want to come back. The state reportable incident for that date documented the elopement and the use of every 15-minute checks but did not document the burn injury, which was later noted on a weekly skin observation as multiple blister sites from self-inflicted burns. In early February, the resident again left the facility after being denied early medication, walking out the front door after announcing they would leave; local authorities later found the resident at a residence identified as a known drug house. The resident eloped again the following day after being denied unscheduled medication and a supervised walk; staff did not realize the resident was missing for approximately 30 minutes, and family found the resident about a mile away at a local business. For each of these elopements, the facility’s intervention remained every 15-minute visual checks, and no new interventions were added to the care plan. Staff interviews further described the resident as independent but needing supervision, with a history of illicit drug use and drug-seeking behaviors, and noted that behavioral triggers often involved not receiving medications when desired. An LPN reported that walking outside with the resident or engaging them in music sometimes helped, and that if the resident became too upset, they would call an ambulance or leave the facility. The DON acknowledged that the facility did not investigate the elopements to determine root causes, although camera footage was reviewed to see when and how the resident exited. The DON noted that on one occasion the resident watched activity around a back door before exiting, and that staff reports of when the resident was last seen were inaccurate compared to camera footage. The DON also stated that the intervention of every 15-minute checks did not appear to be effective, yet this intervention was repeatedly used as the primary response without modification of the care plan, contributing to the failure to provide adequate supervision to prevent further elopement and self-harm.
Removal Plan
- Place the identified resident on continuous 1:1 supervision (line-of-sight monitoring).
- Ensure the assigned 1:1 staff maintains visual contact with the resident at all times.
- Provide uninterrupted 1:1 coverage by relieving the sitter with a designated backup staff member during all breaks.
- Require the charge nurse to assign a backup sitter at the beginning of each shift.
- Document backup staff on the assignment sheet.
- Prohibit breaks without a confirmed face-to-face handoff between sitter and backup.
- Require the 1:1 staff to document every 15 minutes that they have eyes on the resident and the resident’s location on the 15-minute checks sheet.
- Require completed 15-minute check sheets to be turned in to the DON for approval.
- Assign a secondary staff member each shift as designated break coverage to ensure no lapse in supervision.
- Verify door alarm functionality immediately (maintenance and nursing staff).
- Update the resident’s care plan to reflect 1:1 supervision, high elopement risk status, and supervision requirements.
- Complete wandering risk assessments for all residents in the facility.
- Educate all staff on elopement risk, what to do in case of elopement (stay with resident, call 911, ensure safe return, notify charge nurse; charge nurse to notify physician/administrator/DON/family), and 1:1 sitter responsibilities.
- Do not allow staff who missed the education to clock in/work until education is provided and understood.
- Maintain attendance sheets in the education file.
- Review and update the resident’s comprehensive care plan via the interdisciplinary team to include high elopement risk identification, continuous 1:1 line-of-sight supervision, designated break relief protocol with face-to-face handoff, redirection techniques, monitoring frequency and documentation requirements, and conducting an investigation and root cause analysis after any additional exit-seeking behavior to update the care plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Follow Fall Interventions: A resident with dementia, ESRD on dialysis, impaired mobility, and a history of falls was observed ambulating and self-transferring in her room and bathroom without staff assistance, despite orders and a care plan requiring one-person assist with a walker, call light use, frequent safety checks, and skid strips by the bed. Staff interviews confirmed the resident was transferring independently and that the skid strips were not in place as documented.
A resident assessed as high risk for falls did not receive the physician-ordered fall mat on the right side of the bed. Surveyors observed no mat during multiple checks, and the TAR did not reflect the intervention. The resident said the mat had been removed after a new bed was placed, while an RN and the DON acknowledged the order remained in place even though the mat was no longer being used.
Smoking safety interventions were not consistently implemented for four residents who smoked. Two residents were observed smoking with staff supervision but without the smoking aprons listed in their assessments and care plans, and two other residents were also observed smoking in wheelchairs without aprons despite care plan interventions requiring them. The DON confirmed the apron requirement for two of the residents, while the ADON stated residents sometimes complained about the aprons and that he did not know when smoking assessments were completed.
A resident with cerebral palsy, severe cognitive impairment, wheelchair use, and a care plan requiring a mechanical lift for all transfers was manually transferred by a CNA instead of using the lift. During observation, the CNA lifted the resident by the upper back and moved him between the wheelchair and bed without mechanical assistance, despite having completed lift competency training and despite the DON confirming the resident required a mechanical lift for all transfers.
Failure to supervise a resident at risk for elopement led to repeated exit-seeking and wandering events, including being found off the unit and near exterior areas. The resident had dementia with cognitive impairment, hemiplegia, and diabetes, and staff notes described missing documentation of several wandering episodes, an incomplete care plan intervention, and incidents involving a broken alarmed door, a Wanderguard, and an unknown visitor letting the resident off the unit.
A resident with severe cognitive impairment fell during a lift transfer when a sling strap came loose and the chest strap clip broke, and two other residents were observed being transferred with total body lifts using slings that were not verified against their care plans or mobility assessments. Staff interviews showed some CNAs relied on the sling already in the room or on how it fit, rather than consistently checking the care plan or Kardex for the correct sling size and transfer method.
Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure that a resident's fall interventions were in place for one resident reviewed for falls. The resident had diagnoses of dementia and end-stage renal disease requiring dialysis, was documented as having intact cognition but needing supervision with ADLs, transfers, and walker use, and was identified as a fall risk due to ESRD, impulsive behavior, and impaired mobility. The resident's nursing and provider orders directed staff to assist with ambulation, remind the resident to use the call light and wait for staff, and complete frequent safety checks each shift. The resident had a documented fall in which she was found sitting on the floor between her drawer and walker with bleeding from a forehead injury and a skin tear to her jaw, and she was transferred to the hospital where she received stitches. The incident report stated the resident lost her balance when she walked to her drawer to close it. The resident's care plan later identified a self-care performance deficit related to actual falls, weakness, and impaired mobility, and included interventions such as assistance from one staff member with a walker and gait belt, assistance with transfers and toileting, use of assistive devices, skid strips next to the bed, and frequent monitoring for safety. During observations, the resident was seen ambulating and self-transferring in her room and bathroom without staff assistance and at times without using her walker or call light. Staff observed the resident walking independently in her room, and an unidentified staff member passed by without entering the room. The resident stated that she walked and used the bathroom by herself and did not need to follow instructions. Staff interviews confirmed that the resident transferred independently and ambulated without a walker or staff assistance, while another nurse stated the resident was not supposed to self-transfer and that skid strips were not present despite being listed in the care plan. The DON stated that staff were expected to follow resident orders and care plans for safety.
Missing Ordered Fall Mat for High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a resident assessed as high risk for falls received the physician-ordered fall prevention intervention of a fall mat positioned on the right side of the bed. Resident #50 was admitted with diagnoses including orthostatic hypotension, lack of coordination, reduced mobility, and communication deficit. The resident’s fall risk assessment showed a score of 50, indicating high risk for falling, and the care plan identified the resident as at risk for falls and fall-related injury due to a history of falls with fracture, cognitive impairment, and decreased safety awareness. During multiple observations, the resident was seen at the bedside and no fall mat was present on the right side of the bed or located in the room. The physician order dated 6/7/2026 specified a mat on the right side of the bed, but the MAR and TAR did not reflect the fall mat as an implemented intervention. The resident stated the fall mat had been removed after a new bed was placed and had been gone for a long time. An RN stated the resident was a fall risk and that the order for the fall mat should be followed or cancelled if no longer needed. The DON stated the bed had been changed out and the mat would get in the way, and the order should have been cancelled.
Smoking Safety Interventions Not Followed
Penalty
Summary
The facility failed to ensure adequate assessment and implementation of smoking safety interventions for four sampled residents who smoked. Residents #12 and #85 were observed smoking in the designated smoking area with staff supervision on multiple occasions, but neither was observed wearing a smoking apron even though the smoking binder and care plan indicated they needed one. During an interview, the ADON confirmed both residents were listed as needing aprons and stated the residents sometimes complained about the apron, but they should not smoke unless they put it on. The ADON also stated he does not go out with smokers often and does not know when assessments are completed. Resident #12 had diagnoses including COPD, muscle weakness, and epilepsy, and smoking evaluations noted tobacco use and balance problems while sitting or standing; smoking was added to the care plan with a clothing protector intervention. Resident #85 had diagnoses including hemiplegia and right-hand contracture, and although initial smoking evaluations indicated tobacco use with no impairments, smoking was later added to the care plan with a clothing protection requirement. Resident #52, who had CVA with right-sided weakness and paralysis, diabetes, mood disorder, major depressive disorder, and right hand and upper arm contracture, was observed smoking in a wheelchair without a smoking apron despite a care plan intervention requiring one. Resident #11, who had TBI, schizoaffective disorder, major depressive disorder, paraplegia, and upper extremity contractures, was also observed in the smoking area in a wheelchair without a smoking apron, and no attempt was made by the smoking monitor to get the apron on. The DON confirmed that Residents #52 and #11 were supposed to wear smoking aprons when smoking, and the facility smoking policy required residents to be educated and evaluated for smoking upon admission, re-admission, and quarterly.
Failure to Use Required Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to ensure Resident #5 was transferred with a mechanical lift as required. Resident #5 was admitted with diagnoses including cerebral palsy, BPH, and hypertension, and a quarterly MDS showed severe impairment in thinking with a BIMS score of 4. He required substantial to maximal assistance with toileting hygiene, used a wheelchair for mobility, and his care plan documented a history of falls with interventions initiated for a mechanical lift for all transfers to wheelchairs. A POC task also indicated he required a mechanical lift for transfers every shift, and he was listed among residents requiring a sling/mechanical lift. During observation, CNA C provided incontinent care and transferred Resident #5 from his specialized wheelchair to the bed and back without using a mechanical lift. Instead, she manually lifted him by placing her arms around his upper back and interlocking her fingers. In interview, CNA C stated she had been employed for a month, had completed lift competency during orientation, but did not use the lift because she felt comfortable transferring him without assistance and had never used the mechanical lift on him, although other staff did. The DON stated Resident #5 required a mechanical lift for all transfers and that staff could see this in the POC. The facility policy stated mechanical lifting devices shall be used for lifting and moving residents when necessary.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident elopement for a resident who was identified as at risk for elopement and did not reside on a secured unit. The resident had diagnoses including hemiplegia, diabetes, and dementia, and the MDS indicated cognitive impairment. The record showed multiple elopement evaluations with changing results, including several assessments that identified the resident as at risk for elopement in July 2026, while earlier assessments had indicated not at risk or were incomplete. The care plan identified the resident as an elopement risk/wanderer related to impaired safety awareness, but the record contained only one incomplete intervention related to wandering, and no resident preferences were included. Behavior monitoring documented exit-seeking and wandering behaviors on multiple occasions in May, June, and July 2026, but progress notes did not document the behaviors noted on 5/21/26, 6/21/26, and 7/14/26. A physician order for a Wanderguard was created after the resident was found wandering outside on the curb, and staff notes described discussions with family and assessments after the resident was returned to the unit. The resident was later involved in additional elopement-related events. Staff statements and progress notes described the resident being found near a door, in the front hall, in the assisted living area, and off the unit near common areas, with staff searching for her after she was reported missing. One note stated the resident could escape through a security door because the alarm was broken and had not been fixed yet. Another investigation note stated the resident was found off the unit in a common area adjacent to the unit after being let off by an unknown visitor. The facility determined that the resident was cognitively unable to recognize the door requiring a code and would be physically unable to open it without assistance. The report states the facility was out of compliance with resident safety and supervision since 4/12/26.
Failure to verify correct sling size and safe lift use during resident transfers
Penalty
Summary
The facility failed to ensure staff followed accident prevention interventions and safe device use for three sampled residents who required total body lift transfers. The report states that four certified nursing assistants did not verify the correct sling size before transferring residents, despite care plans and the lift’s sling-size identification system directing staff to use specific sling sizes based on resident weight and transfer needs. Resident 39 had severe cognitive impairment, Alzheimer’s disease, dementia with behavioral disturbance, anxiety disorder, and muscle weakness. Her care plan and mobility assessments showed a progression from sit-to-stand lift use to total body lift use with two staff members and a medium sling. On 5/1/26, she was transferred from her wheelchair to her bed by a CNA using a sit-to-stand lift when the sling strap came loose from the hook on the lift and the chest strap clip broke, causing her to fall backward onto the floor. She sustained a skin tear on her right forearm, bruising to the right side of her face, redness to the right side of her body, and a bruise on her right frontal scalp. She was sent to the ER, where X-rays showed no acute findings or fractures. Observations later showed resident 39 being transferred with a total body lift using a large sling, and resident 8 and resident 25 were also observed with large total body lift slings on. Resident 8 had paraplegia, moderate cognitive impairment, and a care plan directing total body lift transfers with a medium and extra-large sling, while his mobility assessment indicated an extra-large sling and two staff members. Resident 25 had vascular dementia and muscle weakness; her care plan directed total body lift transfers with two staff members, and her mobility assessment indicated a large sling. Interviews with CNAs showed that staff sometimes relied on the sling already in the room or judged sling size by how it fit, rather than consistently referring to the care plan or Kardex. The DON and MDS coordinator stated that staff were expected to use the resident’s care plan or Kardex to determine sling size for safe transfers.
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