Repeated Elopements Due to Failed Elopement Risk Management and Wander Guard Oversight
Summary
The deficiency involves the facility’s failure to provide adequate supervision and elopement prevention for a cognitively intact resident with schizophrenia, depression, anxiety, gait abnormalities, obesity, and hypertension, who had a documented history of exit-seeking and elopement risk. As early as 4/23/25, nursing notes documented that the resident attempted to leave the building and had to be redirected. On 6/21/25, the resident left through the front lobby door and was redirected back, prompting an elopement risk assessment that identified the resident as at risk and led to an elopement care plan and an order for an electronic monitoring device (wander guard) on 6/25/25. Despite this, subsequent elopement risk assessments dated 6/23/25 and 9/25/25, completed by a social worker, incorrectly documented that the resident was not at risk for elopement, which the social worker later acknowledged as clinical errors. Exit-seeking behavior on 9/28/25 was documented, but no new elopement assessment or care plan update was completed, and the resident remained on an unsecured floor where residents could freely access the elevator without a code. On 10/12/25, the resident eloped again. Earlier that day, the resident attempted to leave through the front door but was stopped and given Haldol 5 mg by the LPN, who did not report the exit-seeking behavior because the resident had not yet left the facility. Later, the resident could not be located, and a code pink was called; the resident ultimately presented to a hospital stating he had left the nursing facility because he was hearing voices. Hospital documentation indicated the facility nurse reported that the resident had tried to elope earlier and had been medicated. When the resident returned to the facility that evening, open areas were noted on the soles of both feet. Although there was a physician order from 6/25/25 through 10/31/25 to check the electronic monitoring device placement and functionality every shift, the LPN documented "N" (no device in place) for multiple days in October and admitted that the device was not on the resident, that this was not reported to administration or a supervisor, and that the absence of the device was not corrected even after the 10/12/25 elopement. On 2/6/26, the resident eloped a third time, this time from a different unit. The resident had previously been on a secure locked unit (3 North) from 10/15/25 to 1/8/26 without elopements, but after a hospital stay was readmitted on 1/16/26 to an unsecured unit (3 South) where residents knew the elevator code. On the morning of 2/6/26, the LPN on 3 South saw the resident at the elevator stating he was going to the first-floor vending machine, and allowed him to leave the floor unsupervised, not knowing he was an elopement risk and unaware of any wander guard order or device. The resident, who knew the elevator code, reached the first floor, where the receptionist—who did not know the resident was an elopement risk and did not recognize him as a resident—buzzed him out the front door, believing he was staff. The receptionist later stated that the front door wander guard alarm did not sound and that the resident did not have an electronic monitoring device in place. The resident was later found at the hospital after having run, tripped, and fallen, sustaining a closed head injury, chipped and missing teeth, and a lower lip laceration requiring sutures. Throughout these events, staff on multiple units and at the front desk did not consistently know which residents were elopement risks, elopement assessments were inaccurately completed, the care plan was not consistently updated after exit-seeking or elopement events, and the physician order for the electronic monitoring device was discontinued without documented rationale, contributing to the resident’s repeated elopements and injuries. The Immediate Jeopardy was determined to have begun on 10/12/25, when the resident eloped and returned with bilateral foot injuries, and continued through the subsequent elopement on 2/6/26, during which the resident sustained a head injury and oral trauma. The facility’s own interviews and records showed that staff failed to consistently implement and monitor the ordered electronic monitoring device, failed to reassess and accurately document elopement risk after each incident or exit-seeking behavior, and allowed the resident to access unsecured exits and elevator codes despite a known history of elopement. The administrator acknowledged that the resident’s first documented elopement on 6/21/25 was not reported to the state agency and that no incident report or police notification occurred because there was no injury. The DON later confirmed that if a wander guard order exists and the device is not in place, nursing staff are responsible for immediately obtaining and applying a device and notifying leadership, which did not occur in this case. These combined failures in assessment, care planning, communication, and monitoring led to repeated unsupervised departures of the resident from the facility and associated injuries.
Removal Plan
- Reassess all residents for elopement risk and monitor elopement risk assessments to ensure residents are reassessed when there is a change in status.
- Review all resident care plans and revise as needed; review care plans with each change to the elopement assessment.
- Review and update the elopement binder at the front desk and on the units to ensure all residents at risk for elopement with wander guard are listed, including new admissions and re-admissions; review and update the binder with changes in resident status to ensure accuracy.
- Retrain all staff on elopement procedures, including Code Pink procedure, signs of elopement, the elopement policy, and how to identify residents at risk for elopement; retrain staff returning from leave prior to returning to work.
- Conduct Code Pink drills on all shifts to monitor staff response and identify opportunities for additional training; continue Code Pink drills.
- Conduct an ad hoc QAPI meeting with the Medical Director to discuss elopement events and facility follow up.
- Review the elopement policy with the IDT team.
- Update the elevator key code and install a new keypad; instruct staff to know the elevator key code and not disclose it to residents; change the elevator code routinely and remind staff not to disclose the code to residents.
- Audit residents who utilize wander guard and ensure each has a corresponding order to check the device each shift on the MAR and a reminder in the EMR; implement a functionality log to monitor device function and monitor for compliance.
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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