F0689

J

Failure to Prevent Elopement and Unsafe Hoyer Transfer Resulting in Resident Harm

Mattawan, Michigan Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure an area free from accident hazards and to provide adequate supervision to prevent accidents, specifically related to elopement risk and safe mechanical lift transfers. One resident with a history of falls, multiple rib fractures, and recent head trauma was admitted from a hospital with documented confusion, agitation, paranoia, and impulsive behaviors. On admission, the RN completing the elopement assessment marked the resident as not at risk for elopement, despite her own verbal report that the resident was terrified, disoriented, repeatedly stated she wanted to leave, believed people were trying to harm her, and was frequently up and wandering in the room. Progress notes and the admission history and physical documented that the resident was quite confused, agitated, impulsive, and exhibiting abnormal behaviors, including asking staff to help her commit a mass murder, making accusations that hospital staff and paramedics had stolen from her, and expressing delusional beliefs about being harmed. The care plan addressed potential changes in mental status and mood but did not identify or address elopement risk.

Nursing and CNA staff interviews showed that staff relied primarily on the presence of a wander guard to identify elopement risk and did not reference other assessments or tools to determine risk. Staff reported that when a resident was identified as an elopement risk, a wander guard was applied and this was communicated in shift report; if a resident was not assessed as a risk, no wander guard was used and no reevaluation occurred unless triggered by preset intervals or events. The admitting RN initially stated she believed she had documented the resident as an elopement risk, but later clarified she had not, explaining she did not think the resident was physically capable of reaching the door and was hopeful the resident would adjust. Subsequent nursing staff on the night shift were informed only that the resident was new, had fallen at home, had a knot on her head, and was "fine," and they were unaware she was an elopement risk. During that night, the CNA and LPN observed the resident as confused, wanting to call her son, not knowing how she arrived at the facility, asking for her husband and son, and stating she wanted to leave. The resident was kept at the nurse’s station for a time, then assisted back to bed around 3:30 AM. Later, camera footage showed the resident self-propelling in a wheelchair to the main entrance, using the handicap button to open the door, and exiting the building without staff awareness. She walked away from the facility and was not discovered missing until the LPN went to administer medications and found her room empty, prompting a search that ended with the resident being located outside near a neighboring house.

A second deficiency involved the facility’s failure to ensure safe use of a mechanical lift and appropriate sling selection for another resident with moderate cognitive impairment and generalized weakness, who was dependent on staff for all bed mobility and transfers. During a transfer from bed to recliner using a Hoyer lift, two CNAs used a hygiene sling that was present in the resident’s room and that they reported had been used for months. As the lift was pulled away from the bed, the resident was unable to maintain the upper body and arm support required for that type of sling, slid out of the sling, and fell onto the legs of the lift, sustaining a head laceration that required four staples in the emergency department. Therapy staff, including the supervisor of rehabilitation, PT, and OT, later stated that the hygiene sling is a specialized sling intended for toileting, requires sufficient shoulder engagement and core strength, and is not appropriate for routine bed-to-chair transfers without prior assessment. They confirmed that therapy had not assessed this resident for hygiene sling use and had expected a standard full-body Hoyer sling to be used. The RN unit coordinator acknowledged that the hygiene sling had been used, described it as the resident’s preference, but could not provide documentation of such a preference or any assessment supporting its safety for this resident.

Interviews with nursing and therapy staff further revealed that CNAs typically used whatever sling was in the resident’s room and that the resident’s care plan did not specify the type of sling to be used for transfers. There was no documented assessment by therapy or nursing indicating that the resident had the necessary upper body strength and core stability to safely use a hygiene sling for non-toileting transfers. As a result, the resident, who had dementia and Alzheimer’s disease and was dependent for transfers, was transferred with a sling that did not provide adequate support for her condition, directly leading to her fall and head injury during the Hoyer lift transfer.