F0689

J

Failure to Supervise High-Risk Resident Resulting in Elopement and Injury

Bethlehem, Pennsylvania Survey Completed on 02-18-2026

Penalty

Fine: $21,645

Summary

The facility failed to provide necessary supervision and environmental controls to monitor a resident’s location and prevent an elopement. Facility policy on elopement required staff to monitor residents to prevent unauthorized departures. The resident involved had diagnoses including infection and inflammatory reaction due to an indwelling catheter, abnormalities of gait and mobility, and muscle weakness. An MDS assessment documented memory impairment and a need for partial assistance to walk, and the care plan identified that the resident ambulated with a front-wheeled walker and assistance from one staff member. Despite these identified needs, the resident was last seen by staff at 10:00 a.m. walking in the skilled nursing hallway and was not adequately supervised thereafter.

At 11:44 a.m., the resident’s family notified staff that they could not locate the resident when they arrived for a visit. The facility was unaware of the resident’s location or that he had left the skilled nursing area for one hour and 45 minutes. The resident was later found at 12:30 p.m. lying on the concrete floor of a parking garage associated with an independent living apartment area located at the opposite end of a connected building, not part of the skilled nursing units. The resident stated he was cold and was observed with skin tears on the left foot/toes, left leg, and both elbows, dried blood on the back of the head, and a scalp laceration requiring staples. The Administrator reported that they believed the resident exited through unmonitored, unlocked doors leading to the independent living section and then accessed an elevator to the parking garage. There was no evidence that the skilled nursing exit doors were alarmed, locked, or monitored, and residents at risk for elopement had access to this area, resulting in an Immediate Jeopardy situation at F689-J.

Removal Plan

• Resident 1 was assessed by a licensed nurse and sent to the hospital for evaluation.
• All facility residents had a new elopement assessment completed.
• All residents at risk for elopement were communicated to staff and had their care plans/interventions updated.
• All safety devices were checked to ensure they were in place, including electronic devices applied to at risk residents to prevent doors from opening (Wander Guard system).
• An audit was conducted of all skilled nursing community exits.
• A staff member was placed to observe any exits that are not locked at all times until the facility's vendor completes the installation of new locking mechanisms.
• All staff were re-educated on the elopement policy and that staff must monitor the exit doors at all times until the locking mechanisms are installed.
• The Director of Nursing or designee was to initiate weekly audits and report results to the QAPI (Quality Assurance, Performance Improvement) committee.