Failure to Supervise High‑Risk Wanderer Leads to Unnoticed Nighttime Elopement
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment for a resident with severe cognitive impairment and known exit‑seeking behavior, resulting in an unsupervised elopement at night in freezing temperatures. The resident had dementia with agitation, severe cognitive impairment on MDS, and documented wandering 4–6 days per week. Her care plan and physician orders required use of an electronic wandering alarm device, daily function checks of the device, and every‑shift checks of placement and battery, along with frequent safety checks due to high fall and elopement risk. The resident had a prior unsupervised exit from the facility, during which she fell outside the front entrance and sustained a head laceration, and she was identified by the facility as high risk for elopement and placed on 15‑minute observational checks. Despite these identified risks and interventions, the facility’s alarm device system for the 200‑hall exit door had not been functioning properly since early January, and the annunciator for that door produced no audible alarm when a resident with an electronic device approached or exited. The Administrator, DON, and Maintenance Director all acknowledged awareness that the 200‑hall door alarm was not working, that the annunciator had been tampered with to reduce loudness, and that repair would not occur for several weeks. Although other exit doors and their alarms were reported as functional, the 200‑hall door—leading to a back parking lot, wooded area, ditch, and nearby road—remained in use and would open after being pushed for 15 seconds without generating an audible alarm in the building. Security camera coverage of this door was also partially obstructed by a tree and dumpster area, preventing direct visual confirmation of exits through that door. On the evening of the incident, the resident was last clearly observed around 10:45 p.m. when a nurse retrieved her from another hall and returned her to the 200 hall, positioning her near the nurses’ station. The nurse responsible for the resident’s 15‑minute checks then focused on end‑of‑shift computer documentation and did not perform the required checks. At the 11:00 p.m. shift change, there was no clear handoff of responsibility for the 15‑minute monitoring between the off‑going nurse and the oncoming medication aide and NA; staff reported ambiguity about who was responsible for the checks at that time. The NA assigned to the resident began her shift by stocking supplies and answering call lights, assuming the nurse was performing the 15‑minute checks, and did not verify the resident’s whereabouts. Staff on the unit were unaware that the resident had left the building until two unknown individuals, who had found her outside sitting in a ditch, returned her in her wheelchair to a rear door shortly before midnight, at which time she complained of being cold. No staff member could account for the resident’s location between approximately 10:45 p.m. and her return, and the facility later determined by process of elimination and limited camera footage that she had exited through the non‑alarming 200‑hall fire door while wearing her electronic monitoring device.
Removal Plan
- Conducted an immediate full census bed count after Resident #1 was returned; all residents were accounted for.
- Assisted Resident #1 to her room and applied blankets due to complaint of cold.
- Director of Nursing performed a comprehensive assessment of Resident #1 (vital signs, temperature, skin check, injury assessment).
- Continued Resident #1 on 15-minute monitoring checks.
- Implemented 1:1 monitoring for Resident #1 to continue until an electronic monitoring device can be applied when the door alarm annunciator is repaired or until transfer to a secure/locked unit is possible.
- Completed an investigation into the incident (including review of security footage/process of elimination) to determine Resident #1 exited via the 200-hall door and that 15-minute checks were not completed during shift change due to unclear assignment.
- Completed an elopement risk assessment for Resident #1 and determined continued risk for elopement.
- Maintained Resident #1’s picture and name in the facility elopement book (kept at nursing station and front desk).
- Revised Resident #1’s wandering care plan to include 1:1 monitoring and additional interventions (remove from unsafe situations/other residents’ rooms; address basic needs/comfort measures; provide care/activities/daily schedule resembling prior lifestyle).
- Completed an audit of all residents at risk for elopement to ensure appropriate interventions are in place; identified high-risk residents and continued 15-minute checks for all high-risk residents until annunciators are replaced.
- Added a wanderer custom banner flag to the face sheet of all residents identified as high risk for elopement.
- Maintained a list of all residents with the banner flag (DON/designee) and placed it in front of the elopement books at each nursing station and the receptionist desk.
- Conducted an elopement drill (CODE FIND) to heighten staff awareness, observe staff actions per policy, and debrief successes/failures afterward.
- Revised the 15-minute Resident Monitoring Tool to include instructions for initiation/completion of 15-minute checks, formal assignment of staff, how to complete the form, who to submit it to, and shift-time changes so off-going shift completes checks on the hour to allow oncoming shift time for report/assignments.
- Revised the assignment process so the DON/designee completes assignment sheets for 15-minute checks; the NA assigned to the resident is responsible for completing the 15-minute checks; the charge nurse delegates coverage as needed.
- Provided facility-wide in-service education (with teach-back) on the Elopement Policy, location/use of the elopement book, 15-minute monitoring checks (purpose/procedure/documentation), supervision expectations, and ensuring coverage during shift change/breaks/mealtimes.
- Educated staff who are on leave/PRN prior to returning to duty; tracked staff who have not received education (SDC responsible).
- Educated newly hired staff on elopement policy/procedures during orientation (SDC/designee).
- Assigned Administrator and DON ultimate responsibility to ensure implementation of the credible allegation to remove immediate jeopardy.
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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