A resident with dementia, severe cognitive impairment, and wandering behavior left the building after an exit alarm sounded and was later found outside near the solarium. Staff had been aware the resident was wandering overnight and had asked the charge nurse to keep a close eye on the resident, but the resident was last seen in the hallway before being discovered outside. The resident was returned inside with no injuries noted.
Elopement-risk resident exited through unlocked front doors. A resident with schizophrenia, schizoaffective disorder, depression, PTSD, impaired cognition, and a history of removing a wander guard was able to leave when the front doors were opened for a visitor. The receptionist tried to redirect the resident, but the resident became resistive and walked out; staff later found the resident off the property near nearby offices after the resident reported going to a gas station and a church. Interviews and facility documentation indicated the alarm status was unclear and the receptionist did not maintain visual contact with the resident as expected.
Failure to supervise a resident with dementia and known wandering/elopement risk led to the resident leaving a secured unit and being found miles away from the facility. Staff last saw the resident on the 4th-floor unit, but video later showed the resident exiting through a stairwell door that had been accessible with a keypad code, and the facility was not aware of the exit until a family friend reported the resident on a street in a neighboring town. The record also showed hourly rounds were not completed per policy.
Failure to Supervise Resident with Dementia During Unobserved Exit: A resident with vascular dementia, impaired cognition, and mobility deficits left the facility without staff knowledge after moving through the elevator and lobby area and exiting through the front door. The receptionist believed the person was a visitor and did not notify other staff, and the resident was later found safe at home after a neighbor alerted the facility and police completed a wellness check.
A resident with lung cancer, chronic pain, and a history of falls was transferred for a shower and back to bed without the ordered gait belt or rolling walker. Camera footage showed an NA using an unapproved bear-hug technique while the resident appeared anxious, grabbed the shower chair, and later stated, "I can't." Interviews with the Rehab Director, NA, and DON confirmed the transfers were not done per the resident's care plan and physician's order.
Failure to respond appropriately to wander guard alarms and verify a resident before resetting them led to a resident with severe cognitive impairment and high elopement risk leaving the unit and later exiting through a secured exterior door. Staff silenced alarms without confirming the source, did not conduct an exterior search, and did not initiate an immediate search or elopement response. The door’s electronic magnet was also found to be malfunctioning and only intermittently engaged.
A resident with severe cognitive impairment and aphasia left the facility unescorted after the conservator alerted staff that the resident planned to leave and had packed belongings. Staff attempted to apply a wander guard, but the resident refused, and no added supervision, frequent checks, or 1:1 monitoring were started. The DON later treated the event as an AMA discharge rather than an elopement, and the facility did not complete an investigation into how the resident exited or report the incident to the State.
Failure to Use Required Gait Belt During Assisted Transfer: A resident with dementia, gait/balance problems, and fall risk was assisted out of the bathroom with a RW, but an NA did not use the required gait belt and bent down to pick up dropped toiletries during the transfer. The resident fell backward, hit the head, and sustained a laceration requiring ER evaluation and 2 staples.
A resident with dementia and a documented assist-of-1 toileting plan was left alone on a toilet commode without a gait belt, stood up before the aide returned, and fell with wrist pain. Another resident with vertigo and syncope was ambulated at night without the required gait belt, lost balance during a bathroom return, fell, and sustained head and arm injuries requiring ER evaluation and stitches.
Failure to follow a resident’s no-Styrofoam dietary order. A resident with dementia and other behavioral diagnoses had a care plan and MD order for no Styrofoam, after the SLP observed the resident chewing on Styrofoam. During dining observations, the resident was served meals in Styrofoam containers and plates, while dietary staff reported the dishwasher had been broken and meals were being served in disposable Styrofoam containers. The DON/Dietary Services confirmed the resident was served in Styrofoam despite the order.
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