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:
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.