F0689

J

Failure to Prevent Elopement, Hot-Liquid Burn, and Shower-Room Hazards

Mount Pleasant, Texas Survey Completed on 02-23-2026

Penalty

Fine: $17,220

Summary

The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible and to provide adequate supervision to prevent avoidable accidents for a cognitively impaired resident and in a communal shower room. A female resident with severe dementia and other medical conditions, including longstanding atrial fibrillation and stage 3A chronic kidney disease, had a BIMS score of 3 indicating severely impaired cognition. Her MDS showed dependence on staff for toileting, personal hygiene, bathing, and transfers, and that she required at least setup or cleanup assistance with eating and supervision or touching assistance for wheelchair mobility. Her care plan identified her as at risk for wandering and elopement, with interventions including staying with her when exit seeking, notifying the charge nurse, and later one-on-one supervision and structured activities. Elopement risk assessments on multiple dates, including shortly before the incident, identified her as an elopement risk, and progress notes documented wandering and exit-seeking behaviors, including pushing on a locked courtyard door.

On one occasion, the resident exited the facility without staff knowledge and was found outside in the driveway near a busy public street. A nurse taking trash outside saw the resident in her wheelchair in the driveway outside the gate by a hall exit, headed toward the road. Staff interviews indicated the resident had been wandering and exit seeking that day and previously, and that she had been roaming around the facility and “caught the door behind somebody else leaving.” One nurse reported that the alarm on the B Hall laundry exit door did not sound when the resident exited, and a CNA stated that someone, possibly a housekeeper, had left the laundry door open. Staff could not recall how long it had been since they last saw the resident before she was found outside. The DON stated she was notified that the resident had been found outside and brought back in without injury, and that staff had reported the resident had been wandering on the wrong hall and needing redirection, although the DON also stated that, to her knowledge, the resident had not been exit seeking.

The facility also failed to provide adequate supervision to prevent the same resident from spilling hot coffee on herself. The resident’s care plan identified an ADL self-care deficit and later documented that she was at risk of burns from hot liquids, requiring physical assistance with hot liquids, a cup with a lid, protective clothing or lap protector, and upright positioning with a table when consuming hot liquids. An event nurse’s note documented that the resident sustained a burn in the dining room from coffee or another hot liquid, with blanchable redness on the left abdomen and left upper thigh, and that she had cognitive impairment, refused to call for assistance, wandered, required cueing, and resisted redirection. A weekly skin assessment later documented specific measurements of reddened areas on the left thigh. The MDS Coordinator and LVN involved acknowledged that the resident spilled coffee on herself, that she had redness without blistering, and that lids on her drinks were discussed or implemented afterward. Nursing assistants interviewed later reported they had not been instructed which residents required lids on coffee, observed that lids were used inconsistently, and were not aware of any prior burns.

In addition, the facility failed to maintain a safe environment in the Hall C communal shower room. During an evening observation, the shower room door on Hall C was found open and unoccupied, with wet floors and scattered puddles of water. An open cabinet adjacent to the shower stall contained an open K-Quat spray cleaner bottle and a tub and tile cleaner spray bottle on a shelf, and a resident was sitting unsupervised in the hallway across from the shower room. Nursing staff and CNAs interviewed stated that baths and showers were not scheduled on that shift, that they had not assisted with showers that evening, and that cleaning supplies should be stored behind closed cabinet doors with the shower room door closed and locked after use. They acknowledged that a resident could wander into the shower room, slip on the wet floor, or access and spray the cleaning chemicals. The DON and Administrator both stated that all staff were responsible for ensuring safety, that cleaning supplies should be kept out of resident access, and that the shower door should be closed and locked when water was on the floor, and the Administrator confirmed there was no policy addressing accidents/supervision or the shower room and storage of cleaning supplies.

Removal Plan

• One on one monitoring of Resident #1 until discharged from the facility
• Resident #1's care plan was updated
• Trauma Assessment for Resident #1
• Physician notification
• Elopement risk assessments completed for all other residents
• Care plans updated for those determined to be at risk for elopement
• In-service on Elopement and Abuse and Neglect
• Notified families to be mindful of residents attempting to exit the facility and not to share a door code with the residents
• Signage placed at visitor exits to be mindful of residents attempting to exit the facility
• Doors were checked for alarms functioning properly
• Elopement drills were conducted once every shift
• Medical Director was notified
• Visitors were observed through daily rounds for allowing residents to exit the facility unsupervised