Failure to Prevent Elopement and Implement Fall Prevention Interventions
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and assistive devices to prevent accidents, including elopement and falls. One cognitively impaired resident with known exit-seeking behavior was allowed to elope from the facility without staff awareness, and multiple residents at risk for falls did not have care-planned fall prevention interventions consistently implemented. The elopement resident had a BIMS score of 6 indicating severe cognitive impairment, diagnoses including dementia, and a documented history of exit-seeking and wandering behaviors. The resident had an electronic alert band ordered and applied due to exit-seeking behavior, and the care plan identified the resident as at risk for elopement with an intervention to utilize an electronic alert band. Despite this, the resident was last seen in bed around 2:15–2:30 a.m. and subsequently left the building through the front door without staff knowledge. Police found the resident walking alone on a nearby street and returned the resident to the facility around 3:36 a.m., at which time staff documented that the facility had been unaware the resident had left. Staff interviews and observations revealed that the electronic alert system did not function effectively as an audible warning at the nurse’s station. A CNA reported not hearing any alarm when the resident exited, explaining that the sound of the alarm was located between a set of double doors and could not be heard when those doors were closed. The CNA confirmed that the last time she saw the resident, the resident was in bed with eyes closed and appeared to be sleeping. A former LPN stated she only became aware of the elopement when police arrived at the front desk and informed her that the resident had been found outside the facility. The administrator confirmed that the root cause of the elopement was that the electronic alert alarms could not be heard at the nurse’s station and acknowledged that when the system was initially tested, staff only checked the alarm audibility while standing between the double doors, and no one had checked whether the alarm could be heard outside those doors. The social services director confirmed that the resident’s elopement risk care plan had been initiated months earlier due to comments about wanting to leave and wandering behavior, and acknowledged that the interventions in place were not effective since the resident was able to elope. The facility also failed to implement fall prevention interventions as care-planned for several residents at risk for falls and dependent on staff for transfers. One resident with diagnoses including CHF, Type 2 DM, and dependence on enabling machines and devices had an MDS indicating dependence for sit-to-stand and toilet transfers, and a care plan requiring two staff and use of a total body (Hoyer) lift for transfers. Despite this, a CNA was observed transferring this resident from a wheelchair to a toilet using a stand lift alone, and she acknowledged that two staff should perform the transfer but stated she proceeded alone due to short staffing. The restorative nurse and PTA confirmed that if a resident is care-planned for two-person mechanical lift transfers, that plan must be followed for safety. Additional residents at risk for falls were observed with their beds at waist height despite care-planned interventions requiring beds to be maintained in the lowest appropriate position. One resident with hemiplegia and hemiparesis, dependent on staff for transfers and identified as at risk for falls, had a care plan specifying mechanical lift for transfers and ensuring the bed is in the lowest position. During observation, this resident was found lying in a bed at waist height. When questioned, the LPN confirmed the resident was a mechanical lift transfer and acknowledged that the bed was elevated to waist height and should be in the lowest position for safety. Another resident with paraplegia, dependent on staff for chair/bed transfers and at risk for falls, also had a care plan intervention to ensure the bed is in the lowest position. This resident was likewise observed in a bed at waist height, and the LPN confirmed the bed height. The DON stated that beds are to be in low position but noted that some residents prefer higher beds and do not allow staff to lower them, indicating that care-planned fall prevention interventions were not consistently maintained as required by facility policy and resident care plans.
Removal Plan
- Reassessed R75 for elopement risk after the elopement occurred and determined resident remained an elopement risk.
- Located R75 and returned resident to the facility.
- Completed a head-to-toe assessment for R75 with no signs of injury noted.
- Updated R75’s care plan to address the elopement event.
- Notified R75’s family member and Primary Care Physician/Medical Director of the elopement.
- Reviewed facility policies related to the occurrence (Elopement, Routine Resident Checks, Incidents/Accidents, Alarms, electronic alert band, Wanderers, Changes in Condition).
- Updated the Wanderguard policy to include considering alternative interventions in the event of equipment failure (e.g., room change to a more secure floor).
- Updated assessments and care plans for residents at risk for elopement.
- Placed R75 on 1:1 supervision pending move to a more secured unit.
- Moved the only other resident requiring electronic monitoring to a higher/more secured unit.
- Reassessed all residents for elopement risk.
- Implemented a process that all new admissions will have an elopement risk assessment completed per MDS schedule (within 7 days of admission, annually, and as needed).
- Reviewed and updated care plans for residents identified at risk for elopement on admission.
- Placed pictures of at-risk residents in binders at all nursing stations and the receptionist desk.
- Evaluated at-risk residents with active exit-seeking behaviors for possible room change to a more secured unit to limit access to the front entrance door.
- Evaluated at-risk residents to determine whether an electronic monitoring bracelet is appropriate.
- Conducted staff interviews to identify further potential risk.
- Conducted Code drills on all shifts to assess staff knowledge and preparedness.
- Reeducated all staff and managers on routine resident checks, exit seeking, incidents/accidents, elopement policy/procedure, and location of elopement-risk binders.
- Administered staff competency quizzes on elopement.
- Reeducated staff and managers on elopement risk and reporting behaviors/changes related to elopement risk to the appropriate discipline.
- Reeducated reception staff on monitoring front doors, resident safety, and proper Code Green procedure.
- Educated all staff on the electronic monitoring system.
- Implemented monitoring of exit doors by staff when unalarmed.
- Assigned receptionist to monitor the front entrance door.
- Required the receptionist to arm the door and required first-floor nurses to monitor the door when the receptionist is not present.
- Implemented alarm panel checks with a signed monitoring sheet by first-floor staff to ensure door alarms are activated when doors are not monitored by staff.
- Implemented weekly checks of exterior door alarms by the Maintenance Director and EVS Supervisor to ensure alarms are working and doors are secured.
- Met with R75’s daughter to discuss and implement new interventions.
- Initiated a work order to add an annunciator panel to the first-floor nurses station to amplify the alarm.
- Added elopement training to annual abuse training to ensure staff knowledge of elopement plans.
- Started QAA compliance audits using an elopement and door-check audit tool with review at monthly QAPI meetings.
- Assigned IDT members to complete audits and submit them to the Administrator for oversight of completion.
- Started review of audit results regarding elopement and door alarm working condition with the IDT with review at monthly QAPI.
- Implemented an Administrator daily audit to confirm the exterior front door alarm is activated each day by the receptionist prior to leaving.
- Added to new-hire orientation education on elopement and administration of competency quizzes.
- Established that the facility Quality Assurance Team/IDT will meet at least monthly to review elopement-risk residents, trends/patterns, and implement action steps.
- Held an emergency QA meeting with the IDT and Medical Director to discuss the elopement and approve the Removal Plan.
- Assigned ongoing monitoring of the Removal Plan to the Administrator, DON, ADON, and Social Services.
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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