F0689

D

Failure to Prevent Elopement and Accidents for Two Cognitively Impaired Residents

Buffalo, New York Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and effective use of assistive devices to prevent accidents and elopement for two cognitively impaired residents. For one resident with hemiplegia, macular degeneration, severe cognitive impairment, and a history of wandering and off‑unit wandering, the care plan identified elopement risk and required staff to monitor the resident’s whereabouts at all times, keep the resident in common areas for close monitoring while awake, and maintain a wander guard. Despite these measures on paper, surveillance footage showed the resident leaving their room in the early morning hours, attempting to open other residents’ doors and a stairwell door, and ultimately kicking open a stairwell door and entering the stairwell. Over approximately 40 minutes, staff did not identify the resident’s absence until an LPN returning from break entered the stairwell and found the resident at the bottom of the stairs with their wheelchair on top of them, resulting in injuries that required hospital evaluation.

Interviews and records showed multiple supervision and system gaps related to this event. The assigned CNA reported doing rounds at 1:00 a.m. and then sitting at a desk between two pods with double doors closed, which could limit the ability to hear alarms from the opposite pod. Several staff, including CNAs and LPNs, stated they did not hear any door alarm sound around the time of the incident. The nursing supervisor and an LPN tested the stairwell door alarm after the incident and reported it only sounded once despite multiple attempts. The DON and unit manager confirmed that the second‑floor stairwell doors did not have badge swipes, magnetic locks, or wander guard integration, and that alarms sounded only locally on the floor. The DON later concluded that the resident was able to access the stairwell and fall because the staff assigned to them were caring for other residents and that closed double doors between pods could have prevented staff from hearing any alarm.

The second resident involved had congenital alveolar hypoventilation syndrome, epilepsy, a tracheostomy, severe cognitive impairment, and was typically attached to an electronic sensor that alarmed at the nurses’ station when disconnected. This resident’s care plan required supervision in the room and on the unit when ambulating, but did not identify elopement risk or exit‑seeking behavior. Progress notes documented that the resident was becoming more engaged in therapy, more stable on their legs, and gaining new skills. A nursing note described that the resident removed their sensor and attempted to run off the unit, being seen and redirected by staff; the unit door was also noted to be malfunctioning and not latching properly. Despite this documented exit‑seeking behavior, there was no evidence that an updated elopement risk assessment was completed, no new elopement interventions were added to the care plan, and no wander guard was applied before the resident later left the building.

Subsequent documentation and interviews confirmed that the elopement attempt and exit‑seeking behavior for this second resident were not effectively communicated or escalated. The 24‑hour report sheets and interdisciplinary progress notes contained no ongoing monitoring or follow‑up for exit‑seeking after the initial attempt. The DON, social worker responsible for elopement risk scales, and the former interim unit manager all stated they were not informed of the earlier attempt and therefore did not reassess the resident or implement additional safety measures. Nursing staff acknowledged that typically a wander guard would be placed after an elopement attempt, but this did not occur. Later, the resident removed their sensor again, exited through double doors used for school transport, and was found outside on the sidewalk by an environmental services staff member, who returned the resident to the unit. The lack of reassessment, care plan revision, and preventive interventions after the first documented exit‑seeking episode contributed directly to the subsequent elopement.