F0689

G

Failure to Prevent Elopement and Injury Due to Inadequate Supervision and Noncompliance With Transfer Protocols

Huron, South Dakota Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents. In the first incident, a resident with severely impaired cognition, as evidenced by Brief Interview for Mental Status (BIMS) scores of three and zero on prior assessments, had been identified as a high elopement risk with elopement risk assessment scores of five on two separate dates. Her care plan prior to the incident included non-pharmaceutical interventions for wandering, such as cueing, reorienting, supervising, use of an animatronic dog, conversation, walking with her, inviting her to activities, encouraging rest, and providing less stimulation when she was anxious, delusional, or wandering. Despite these identified risks and interventions, the resident was able to exit the building through the front door without staff knowledge.

On the date of the elopement, the resident was ambulating with a walker throughout the facility and followed a staff member who was leaving the property out the front door. She exited the building at 2:48 p.m. and was seen outside in the parking lot by the front door at 2:50 p.m., at which time she was escorted back into the facility. The DON later stated that during this elopement, a staff member let in five family members through the front door, which crowded the receptionist’s direct line of sight and prevented the receptionist from seeing the resident use her walker to leave the facility. The DON also stated that residents were mobile and deemed elopement risks, and that if they got outside, it was considered an elopement based on facility policy. The facility’s elopement policy required the facility to take steps to keep residents safe and assess residents to identify those at risk for elopement.

The second incident involved a resident with a care plan indicating she was to be transferred with one-person assistance using a walker and a gait belt, and who had been assessed as being at high risk for falls. On the date of the fall, a CNA assisted this resident from a bath chair to her wheelchair without using a gait belt, contrary to the resident’s care plan and the facility’s Transfer and Gait Belt Use policy. During the transfer, the resident was unable to continue standing, and the CNA eased her to the floor, where she was found lying on her right side at the foot of her bed. Assessment by an LPN revealed a one-centimeter skin tear to the right eyebrow, which was closed with a steri-strip, and a light blue bruise measuring ten centimeters by three centimeters on the right upper arm. The resident’s range of motion, neurological assessments, and vital signs were within normal limits, and she reported pain at a level of three on a zero-to-ten scale. The CNA later confirmed he knew a gait belt was required for this resident but did not use one and was unsure why.