Elopement of High-Risk Resident Due to Inadequate Supervision and Failed Wander Guard Protections
Summary
The deficiency involves the facility’s failure to ensure a safe environment and provide adequate supervision to prevent an elopement for a cognitively impaired resident with known wandering and exit-seeking behaviors. The resident had been admitted with multiple serious diagnoses, including traumatic subarachnoid hemorrhage, psychotic disorder, malnutrition, dysphasia, and a wedge compression fracture, and was assessed on the admission MDS as severely cognitively impaired with a BIMS score of 4. The admission assessment documented wandering behaviors on 1–3 days in the lookback period and a need for moderate assistance with ambulation. An elopement risk assessment completed on admission showed a score of 31, identifying the resident as at risk for elopement, with cognitive impairment, decreased safety awareness, judgment disturbances, a history/risk of wandering, and a history of one or two prior elopement events. Nursing documentation on 1/1/2026 described the resident as exit seeking several times after visitors left, stating he would leave when staff were not looking, and a physician’s order was obtained for a wander guard bracelet with every-shift checks for placement. Despite these findings, the resident’s care plan dated 12/18/2025 did not address wandering or exit-seeking behaviors prior to the elopement. The care plan at that time only referenced a behavior problem with general interventions such as speaking calmly, diverting attention, and removing the resident from situations as needed. The DON later acknowledged in interview that the resident had not been care planned for wandering or exit seeking before the incident and that he should have been. The facility’s elopement and wandering policy stated that residents at risk for elopement would receive adequate supervision, that interventions would be added to the care plan and communicated to staff, and that door locks/alarms and wander guard systems were in place but not a replacement for necessary supervision. However, there was no evidence that the resident’s identified elopement risk and exit-seeking behaviors were incorporated into a person-centered care plan or that specific interventions for wandering were implemented before the event. On the day of the incident, video footage showed the resident exiting the building through the front lobby without staff knowledge or assistance. The resident, wearing only a long-sleeved shirt, pants, and shoes, followed a visitor through the first set of doors, passed the receptionist, then followed the visitor through the second set of doors, walking past a housekeeper who was cleaning the lobby foyer. The resident then exited the front entrance and walked away from the facility along snow- and ice-covered walkways and roads in 21°F weather. The facility was not aware the resident had left until a family member called the receptionist to report that the resident was at a relative’s home, at which point a code white was initiated and a head count performed. Interviews and documentation indicated that the wander guard system at the front entrance did not alarm when the resident exited, and the Administrator later stated that the wander guard was not working properly at that time. The resident was ultimately found at a family member’s home after having fallen on an icy surface while exiting a private vehicle, and subsequent assessment and radiology confirmed an acute intertrochanteric fracture of the right hip. The facility’s failure to supervise the resident and to ensure that the elopement prevention systems and care planning were effectively implemented resulted in an Immediate Jeopardy citation at F689.
Removal Plan
- Completed a medical assessment for Resident #1 by the charge nurse and notified the Physician/Nurse Practitioner (NP) via the Assistant Director of Nursing.
- Administrator notified the physician and pain medications were administered as ordered by the charge nurse for Resident #1.
- Obtained an X-ray per physician orders for Resident #1; results showed an acute intertrochanteric right hip fracture; charge nurse notified Physician/NP and transferred Resident #1 to the hospital.
- Verified resident census and confirmed all residents present in the facility.
- Updated Elopement Risk Assessments for current residents to identify high elopement/wandering risk residents.
- Reviewed and revised care plans for all high elopement/wandering risk residents; updated interventions including wander guard placement for residents identified as high risk.
- Re-educated staff on the elopement/wandering policy, timely response to alarms, supervision expectations, and location of the Wander Guard Elopement Risk Binder; required completion prior to working.
- Revised maintenance procedures for auditing Wander Guard doors to include inspection of Wander Guard alarm panel integrity and hardware.
- Placed pictures and profiles for high-risk elopement residents with wander guard bracelets in the Elopement Risk Binder at the Reception Desk and at each nurses’ station.
- Provided 1:1 education to the housekeeper present at the door regarding recognizing wanderers/high elopement-risk residents and being observant in exit areas.
- Provided 1:1 education to the Maintenance department to check structural integrity of the wander guard door alarm system in addition to normal testing.
- Conducted elopement drills until all staff completed a drill and understood the process.
- Implemented Wander Guard alarm testing and door checks (including structural integrity) twice daily by Maintenance and/or Administrator; discussed results in QAPI and adjusted monitoring frequency based on audit results.
- Inspected the Wander Guard system; identified the front entrance panel as loose due to wear and tear; repaired immediately and tested the system as working correctly.
- Initiated enhanced monitoring at the reception area, including a Front Desk Visitor Screening Audit Log and Back Up Monitoring Log; educated Business Office Manager and Reception staff on these processes.
- Held an ad hoc QAPI meeting to review the incident, timeline, and immediate corrective actions with Medical Director participation.
- Implemented ongoing audits using the Wander Guard Door Alarm Audit and Front Desk Visitor Screening Audit Log.
- Completed vendor inspection and repair of the Wander Guard system by State Systems.
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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