F0689

J

Failure to Prevent Elopement and Implement Fall Prevention Interventions

Orland Park, Illinois Survey Completed on 03-19-2026

Penalty

No penalty information released

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.