Failure to Prevent Elopement for Two Residents: Two residents with documented dementia, cognitive impairment, and wandering or exit-seeking behaviors were identified as elopement risks and had Wander Guards in place, yet each was found outside the facility unsupervised. One resident was located near a gas station after leaving without an alarm sounding, and another was reported by a community member walking along a road before staff found and returned the resident.
A resident with a BIMS of 15, walker use, and continuous O2 was injured when her wheelchair tipped backward during van transport. The driver failed to secure the wheelchair’s front clamps, and the resident reported hitting her head and sustaining a skin tear to her upper arm after the chair flipped and struck items in the van.
A resident with aphasia and moderate cognitive impairment eloped from the facility without signing out or notifying staff. Staff later discovered the resident was missing during a med pass, searched the building and grounds, and learned from family that she had been taken to the hospital. EMS found her next to her motorized scooter, agitated and confused, and the ER documented encephalopathy and presumed heat stroke. Interviews showed the facility expected residents to notify the nurse and sign out when leaving, but the resident had no prior elopement history and was not located until after she had already been transported to the hospital.
A resident with a prior elopement history, moderate cognitive impairment, and use of a motorized wheelchair was allowed limited independent travel and had inconsistent care plan documentation regarding a wander-guard and supervision needs. The resident signed out to the portico, was later found missing, and was located at home about 24 miles away after a code pink was called. Staff interviews and the record showed the resident was not accompanied as planned and a staff member who saw him leaving did not stop him or notify others.
A resident with Parkinson's disease, epilepsy, neuropathy, bipolar disorder, pain, and later-documented moderate cognitive impairment was care planned to be supervised while smoking and to have smoking materials stored by staff between smoking times. However, observations showed the resident obtaining a lighter, going to the smoking patio, and smoking independently with no staff present, including while smoking with other residents. Staff interviews confirmed that residents deemed independent smoked alone, while those needing supervision were supposed to have a staff member stay with them the entire time, and the DON acknowledged the care plan wording was confusing.
A dependent, quadriplegic resident with intact cognition and high fall risk, who required two‑person assistance for bed mobility, fell from the bed during a brief change when CNAs attempted to roll the resident while positioned too close to the bed’s edge. The resident slipped off the side of the bed, landing on the floor and sustaining minor abrasions and knee pain. Staff interviews and documentation showed that the resident had not been adequately moved toward the opposite side of the bed before rolling, contrary to the facility’s own procedures for safely turning dependent residents, leading to a preventable fall during in‑bed care.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
Unsafe Smoking Supervision and Storage: A resident with schizoaffective disorder, anxiety, and multiple sclerosis was assessed as unable to smoke safely without assistance, yet staff observed the resident smoking with tremors, dropping ashes and a cigarette, and without a smoking protector. The record and staff interviews showed inconsistent practices about whether smoking materials could be kept on a resident’s person, while the resident had already received a smoking violation for having a lighter or matches.
A resident with dementia, moderate cognitive impairment (BIMS 8), gait and mobility deficits, and documented wandering/exit-seeking behaviors eloped after being last seen by an LPN during morning meds and stating he was going to the dining room. Despite prior notes identifying wandering and elopement risk as barriers to discharge and care plans addressing dementia and behavior problems, a wander risk assessment was not completed on admission. Video showed the resident at the front door with no staff present until a security officer arrived from outside, misidentified the resident as a visitor based on brief questioning, and allowed him to exit. The resident then left the property and was later located and returned by family, while the facility’s investigation found that security failed to follow protocols for verifying whether the individual leaving was a visitor or a resident.
A cognitively intact resident with Huntington’s disease and significant behavioral issues participated in a group activity using toy guns and foam darts, where residents were not positioned as the activity director required to prevent darts from striking others, and the sole activity aide left the room briefly, leaving all participants unsupervised. Another cognitively intact resident with a history of suicidal ideation, substance use, homelessness, and extensive incarceration was assessed as low risk for wandering/elopement using a tool that did not address psychosocial or substance‑use factors, and later left the premises by car during an unsupervised smoking break after requesting a dressing change be delayed until after smoking. Subsequent observation showed multiple residents smoking outside without staff present while the receptionist remained inside, despite facility policies requiring adequate supervision, elopement risk assessment, and activity programming coordinated with comprehensive assessments.
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