Failure to Supervise Resident Who Left on LOA With PICC Line and Recent Toe Amputations
Summary
The deficiency involves the facility’s failure to implement appropriate supervision and safety interventions to prevent a resident from leaving the facility unsupervised and engaging in unsafe behaviors, despite known substance use history and medical vulnerabilities. The resident had been admitted following a hospitalization for bilateral lower extremity pain, osteomyelitis of two toes, and subsequent toe amputations, and was discharged from the hospital with a PICC line for IV antibiotics. Hospital records showed the resident had tested positive for amphetamines and cannabinoids prior to admission. On admission, the resident signed a Substance Use Disorder Program (Stepping Stones) consent that outlined safety measures including supervised visits, restricted visitation hours, random searches, and no LOA without collaboration with the counselor, IDT, and physician. The resident’s elopement assessment rated him as low risk, and his care plan documented a substance abuse disorder with an intervention that he would follow the Stepping Stones protocol. The resident’s admission assessments documented intact cognition with a BIMS score of 15, bilateral lower extremity impairment, use of a wheelchair or scooter, and a surgical wound on the right foot. Despite the Stepping Stones consent and the documented plan that the resident would follow the program protocol, the facility did not actually implement the program because there was no counselor available, and no additional supervision or interventions were added based on his needs. The Regional Director of Clinical Services confirmed that although the resident signed the consent and the care plan referenced following the Stepping Stones protocol, he was never actually placed on the program. The Admission Director stated she had informed the resident he was not allowed to leave without supervision, but also reported that the Administrator told the resident that if he could find a way to get his motorized wheelchair, he could do so. Staff interviews showed that multiple staff were aware the resident was focused on obtaining his power chair and was likely to leave, but there was confusion about his LOA status and no clear restriction or supervision was enforced. On the day of the incident, the resident signed himself out in the LOA book without verbally notifying staff and left the facility in a friend’s car to retrieve his motorized wheelchair. CNA staff knew he planned to leave to get his wheelchair but were unsure of the time and believed he did not have privileges to leave; the LPN on duty believed the resident was going to leave that day and later realized the resident had signed out by accessing the LOA book himself. The facility investigation documented that the police contacted the facility about someone having escaped, and staff reported the resident was on LOA and safe. The Admission Director communicated with the resident by cell phone while he was away and reported to the Administrator that he would be riding his wheelchair back, but the Administrator declined to have staff pick him up. The resident then traveled approximately five miles back to the facility in his motorized wheelchair, wearing regular clothes with a hospital gown, stopping at private and public locations, including a tavern, to charge the chair. Staff, including the ADON and LPN, were aware he was riding back unsupervised, and the physician later stated he would have preferred the resident sign out AMA if leaving without supervision due to the PICC line. The resident ultimately returned to the facility that evening, where he was assessed, but the deficiency centers on the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and safety interventions to prevent the unsupervised departure and unsafe behaviors. Observation of the resident after the incident showed he had a PICC line in place, a surgical boot on his right foot, slightly unsteady gait, and a large motorized wheelchair in his room. The resident reported that he knew he was not supposed to leave unsupervised based on prior conversations with administration but chose to leave to obtain his chair. He stated he informed the facility while away and asked to be picked up, but was told they would not pick him up, requiring him to ride and at times push his wheelchair back, stopping multiple times to charge it. Staff interviews corroborated that the resident’s picture appeared on social media while he was out, that staff saw him in the community wearing a hospital gown over his clothing, and that the facility considered him to have signed out LOA because he had a BIMS of 15 and was alert and oriented. The Administrator later stated that because the Stepping Stones program was no longer offered, the resident did not have restrictions in place, despite the signed consent and care plan references. This sequence of events, combined with the lack of implemented safety measures and supervision, formed the basis of the cited deficiency under F689 for failure to ensure the environment was as free of accident hazards as possible and that the resident received adequate supervision to prevent accidents.
Plan Of Correction
Preparation and submission of this plan of correction does not constitute an admission or agreement by the provider of the truths of the facts alleged or correctness of the conclusions set forth on the statement of deficiencies. This plan of correction is prepared and submitted solely because of the requirements under the state and federal law. This plan of correction will serve as the Facility's allegation of substantial compliance and completion with an allegation of compliance date of 4/28/2026. Resident #2 no longer resides in the facility. On 4/23/2026 the Director of nursing/designee identified and interviewed all like residents with a BIMS 13 and higher to address any needs expressed of belongings needed outside of facility. No one identified any needs outside of facility. Director of Nursing/designee will educate all staff that if the any resident has any needs outside of the facility to fill out a concern form and give concern form to Social Service or Administrator to be addressed. This will be completed by 4/28/2026. Director of Nursing/designee will educate all staff to include LOAs, and will be completed by 4/28/2026. Residents requiring supervision for LOAs were reviewed on 4/23/2026 by Director of Nursing to ensure they are receiving appropriate supervision when needed. To ensure the deficient does not recur the Director of Nursing/designee will audit any new admissions for assistance with outside needs x 4 Weeks then continue compliance with daily room checks done by all department managers daily Monday thru Friday.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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