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:
Failure to ensure effective fall alarms and supervision: two residents had Smart Caregiver monitoring devices set to LOW volume, and one resident's bed alarm did not alert staff before the resident was found on the floor after an unwitnessed fall. One resident had dementia, osteoporosis, prior TIA, and cognitive impairment and was fully dependent on staff, while staff also found that a second resident's bed and recliner alarms did not activate properly during testing.
Failure to assess the safety of perimeter mattresses for two residents. Both residents had severely impaired cognition and significant mobility limitations, and both care plans included use of a perimeter mattress to define the edges of the bed. However, their Mobility, Physical Device, and Fall Risk assessments lacked documentation of a perimeter/defined edge mattress assessment. Staff interviews showed inconsistent understanding of the required order, IDT review, engineering review, and safety assessment before use.
Improper Mechanical Lift Transfers: A resident with dementia, spinal cord dysfunction, and dependence for transfers was supposed to be moved with a full-body mechanical lift and two staff members, but a TMA stated she transferred the resident alone. The resident reported that staff sometimes used only one person for lift transfers because of staffing shortages, while other staff and the DON stated this was unsafe and against policy.
Two residents were involved in accident-hazard deficiencies. One resident with cancer, PVD, and Alzheimer’s disease was observed in a wheelchair with feet extending past short footrests, with the lower legs resting against the hard footrests despite a care plan entry for padding. Another resident with dementia and a hx of falls had an unwitnessed fall, but ordered orthostatic BP monitoring was not completed accurately and staff reported no post-fall PT referral was received.
A resident was given a new electric wheelchair without a prior therapy assessment and could not stop the chair, causing it to strike a bed frame and resulting in a leg laceration, tibia/fibula fractures, and a syncopal episode from blood loss. Another resident with cognitive impairment and high fall risk continued to self-transfer and fall, but the care plan was not updated with new fall interventions after repeated incidents.
A CNA used a Hoyer lift alone to weigh one resident, and another CNA was observed using a Hoyer lift alone to weigh a second resident. One resident’s care plan called for a 2-assist Hoyer lift, and the facility’s lift competency checklist and policy both required two caregivers for mechanical lift use; the DON and Director of Therapy also stated that two staff members are always required.
Failure to Ensure Effective Fall Alarms and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and effective use of assistive fall-prevention devices for two residents who were reviewed for fall precautions. One resident had diagnoses including unspecified dementia, age-related osteoporosis, a history of transient ischemic attack, and cognitive impairment, and was described by the POA as weak, bedbound, and unable to participate in physical therapy after a prior right femur fracture. The resident was completely dependent on staff for eating, hygiene, mobility, and toileting, and the care plan included a bed alarm per orders. The resident was found on the floor next to the bed after an unwitnessed fall. The POA reported receiving a call from the facility that the resident had been found on the floor and was not injured, and stated the resident frequently forgot to ask for help and had tried to get up without assistance before. A nurse stated the bed alarm was not heard when the resident fell, and the facility was unable to provide evidence that the bed alarm functioned as intended or alerted staff before the resident was found on the floor. The event report identified the fall as unwitnessed and did not indicate that a bed alarm alerted staff. The facility also failed to ensure the Smart Caregiver sensor pad monitoring system used for another resident was functioning properly and set at an audible volume. Two Smart Caregiver monitor boxes at the nurses' station for that resident's bed and recliner were observed set to LOW volume, and the chime settings faced the back wall of the desk. When a CNA tested the recliner alarm from the resident's room, the monitor at the nurses' station did not illuminate or sound an alert on either attempt. The CNA changed the batteries but did not retest the device, and both CNAs stated they could hear alarms only if they were near the nurses' station and did not recall training on operation or testing of the devices. The facility director stated the facility did not perform preventive maintenance on the devices and relied on staff to ensure they functioned properly.
Failure to Assess Safety of Perimeter Mattresses
Penalty
Summary
The facility failed to ensure that 2 residents with perimeter mattresses were assessed for safety. One resident had a significant change MDS showing severely impaired cognition, dementia, reduced mobility, muscle weakness, and need for assistance with bed mobility, sitting, standing, and transfers. That resident’s care plan identified limited physical mobility related to dementia with mood disturbance and anxiety, a genetic muscle disorder, spinal stenosis, and osteoarthritis, and included use of a perimeter mattress to help find the edges of the bed for bed mobility. However, the resident’s Mobility, Physical Device, and Fall Risk assessment lacked documentation of an assessment for a perimeter/defined edge mattress. The second resident’s annual MDS showed severely impaired cognition, dementia, multiple sclerosis, repeated falls, and need for partial to moderate assistance with bed mobility. The care plan identified limited physical mobility related to weakness, falls, incontinence, hypertension, renal disease, dementia, MS, depression, and delusional disorder, and included use of a bariatric sized bed with a perimeter mattress to define the edges of the bed. That resident’s Mobility Physical Device and Fall Risk assessment also lacked documentation of an assessment for a perimeter/defined edge mattress. During observation, the resident was in bed asleep with a perimeter mattress. Staff interviews showed differing understanding of whether a physician order, assessment, IDT review, engineering review, and safety assessment were required before use of a perimeter mattress, and the DON confirmed both residents’ most recent assessments lacked documentation of a perimeter/defined edge mattress assessment.
Improper Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure transfers were performed according to R24’s assessed needs, care plan interventions, and facility policy. R24’s records showed she had diagnoses including non-traumatic spinal cord dysfunction, diabetes, dementia, depression, heart failure, and asthma. She was dependent on staff for toileting and transfers, was frequently incontinent of bowel and bladder, and had care plan directions for assistance with transfers using a full-body mechanical lift and two staff members. During interviews, a TMA stated she transferred R24 with the full-body mechanical lift by herself because R24 needed to use the bathroom and she felt the transfer was safe. R24 stated staff sometimes transferred her with only one staff member and said they told her there was not enough staff. Other staff interviewed stated transfers with the full-body mechanical lift using one staff member were unsafe and should not occur. The facility policy for using a mechanical lift stated that at least two trained associates are needed to safely move a resident with a mechanical full-body floor-based lift or ceiling/overhead full-body lift.
Unsafe Wheelchair Fit and Incomplete Post-Fall Monitoring
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. Resident 27 was readmitted with diagnoses including cancer, peripheral vascular disease, and Alzheimer's disease and was sometimes able to make needs known. On multiple observations, Resident 27 was seated in a slightly tilted back wheelchair with feet extending beyond the footrests, and the back of the lower legs rested against the hard footrests above the ankle/heel area. A pillow was observed either on the floor or behind the legs rather than padding the footrests. The focused care plan for skin integrity included padding to wheelchair footrests, and staff interviews confirmed the footrests were too short and needed adjustment or replacement, but staff had not notified therapy or otherwise addressed the wheelchair fit. Resident 50 was admitted with diagnoses including dementia, history of falls, and UTI and was sometimes able to make needs known. The care plan identified the resident as at risk for falls. After an unwitnessed fall in the 300 hallway, the incident investigation added interventions to monitor orthostatic blood pressures and refer to physical therapy. However, the record showed an orthostatic blood pressure order on 05/20/2026 was not completed, and subsequent orthostatic blood pressures recorded the same blood pressure and pulse for all three positions on 05/22/2026, 05/23/2026, and 05/24/2026. Staff later stated they had not received a post-fall therapy referral, and the DNS stated the resident should have had orthostatic blood pressures taken accurately to rule out orthostatic hypotension.
Failure to assess electric wheelchair use and update fall interventions
Penalty
Summary
The facility failed to comprehensively assess a resident for the use of an electric wheelchair and failed to develop new interventions to reduce fall risk for another resident. The report states that the facility’s policies required a device evaluation before an electric wheelchair was initiated, resident education and consent, and an updated service plan identifying device use and other interventions. The fall management policy required individualized care plan updates, a systematic review after each fall, identification of root cause, and review of prior interventions when new interventions were implemented. Resident 73 was admitted with weakness and lymphedema and had an above-the-knee left leg amputation, requiring assistance with bed mobility, transfers, and locomotion. The resident’s record showed cognitive intactness, lower extremity impairment, supervision or touch assistance for bed-to-chair transfers, and use of a manual wheelchair. On 4/17/26, a newly issued electric wheelchair was delivered and the resident was assisted into it. The resident reported that the representative showed how the chair worked but not enough, and that the resident did not know how to stop it. The resident then returned to the room, could not stop the chair, and the chair continued forward into the bed, causing the resident’s right leg to strike the metal bed frame. The resident sustained a five-centimeter laceration to the right anterior lower leg, fractures of the right tibia and fibula, and a brief syncopal episode secondary to blood loss. The resident also received an anticoagulant, which contributed to significant bleeding. The clinical record contained no evidence that the resident had been assessed to safely operate the electric wheelchair before use. Resident 3 was admitted with a right total hip replacement with deep hardware removal and post-traumatic osteoarthritis of the right hip. The resident had a high fall risk on Morse Fall Scale assessments, cognitive impairment on OT evaluation, and a PT evaluation showing a score of zero on the Short Physical Performance Battery, indicating high fall risk and increased risk of mobility disability. The resident fell on 3/31/26 after getting up independently and sustained a right femur fracture requiring surgical repair, and fell again on 5/12/26 after getting up independently and sustained a skin tear to the right elbow. The care plan identified fall risk and included reminders to use the call light, non-skid socks, and one-person assistance for toileting and transfers, but revisions to the care plan did not add new or amended fall prevention interventions. Staff statements indicated the resident continued to self-transfer and toilet without assistance, staff believed the resident was independent, and the existing fall prevention interventions were ineffective.
Unsafe One-Person Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure safe use of a mechanical lift for 2 of 3 residents reviewed for accidents. During an observation on 6/2/2026 at 8:42 AM, Resident #4 was lying on his bed on top of a Hoyer pad while CNA Staff K stood on the right side of the bed with a mechanical lift; the lift hand bags were observed over the resident, and no other staff member was in the room. Staff K stated that he was weighing Resident #4 and that normally only one person uses the Hoyer lift for weights, although the resident’s care plan documented a Hoyer lift with 2 assist. On 6/4/2026 at 10:15 AM, CNA Staff D was observed using a Hoyer lift alone to obtain Resident #13’s weight, with the resident lifted approximately 12 inches off the mattress in the sling and no other staff present. Staff D stated that he was performing weekly weights and most of the time did the weights using the Hoyer lift by himself. Resident #13’s MDS Section GG coded the resident as dependent, and the facility’s mechanical lift competency checklist stated that two caregivers are present, while the facility policy for using a mechanical lifting device stated that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The DON and Director of Therapy both stated that a mechanical lift should always be used by two staff members.
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