Failure to supervise a resident at risk for elopement led to repeated exit-seeking and wandering events, including being found off the unit and near exterior areas. The resident had dementia with cognitive impairment, hemiplegia, and diabetes, and staff notes described missing documentation of several wandering episodes, an incomplete care plan intervention, and incidents involving a broken alarmed door, a Wanderguard, and an unknown visitor letting the resident off the unit.
Failure to maintain safe resident environments: one resident with a history of falls and wheelchair use was found on the floor after the ordered bedside wheelchair intervention was documented, another resident did not have dycem placed as ordered on the wheelchair seat cushion, and a third resident had an air mattress placed without a documented safety-hazard assessment. The DON confirmed the missing assessment, and staff confirmed the wheelchair order was not fully followed.
Failure to Place Ordered Bilateral Fall Mats: A resident with CVA, left hemiplegia, generalized weakness, and HTN had a physician order and care plan directing padded fall mats on both sides of the bed while in bed. Although the resident was dependent for bed mobility and transfers and had a fall risk/history of falls, staff observed only one padded fall mat on the right side of the bed, and the DON confirmed bilateral mats were supposed to be in place.
A resident’s medication cup containing two pills was found on the bedside table while the resident was away from the room. An LPN Unit Manager confirmed the medication belonged to the resident and that there was no physician order for self-administration; the NHA identified the pills as Sevelamer Carbonate 800 MG and Cinacalcet HCl 30 MG.
Failure to Reassess Supervision Needs After Stairwell Access Incident: A cognitively intact resident with COPD, gait and mobility issues, type 2 DM, an open leg wound, and acute kidney failure gained access to a stairwell and was sent to the hospital for evaluation. After the resident returned with no injuries, the record showed no documented reassessment of supervision or safety needs, and the DON stated that 1:1 supervision should have been in place on readmission but was not started until later.
A resident with bipolar disorder, psychosis, impulsiveness, suicidal and homicidal ideations, and repeated elopement-risk scores repeatedly left or tried to leave the building and cut off a secure care device using utensils taken from the dining area. Staff documented multiple episodes of wandering, entering other residents’ rooms, and attempting to exit through the front door, while survey observations found butter knives, scissors, a screwdriver, pliers, and fingernail clippers accessible in common areas and at nurse stations.
A resident with difficulty walking and bilateral knee contractures had a care plan and Kardex directing max assist of 2 for bed mobility. While an aide was providing care with the resident lying on his side, the resident rolled out of bed and sustained pain to the right ankle, knee, and hip. Hospital records showed a closed right distal femur fracture requiring surgery, and the administrator stated the aide did not follow the resident’s plan of care and should have had another staff member assist.
A resident with traumatic brain injury, CVA, diabetes, DVT, moderate cognitive impairment, and multiple safety risks was left seated in a wheelchair while a maintenance employee repaired it. The wheelchair unexpectedly reclined backward during the repair, causing the resident to hit the head against the wall and sustain a skin tear to the forearm; the employee later stated the wrong mechanism released and that the resident had not been removed from the chair during the work.
Unanswered exit door alarms at the smoker’s patio were repeatedly observed sounding at the nurses’ station while staff did not respond to check the door or residents in the area. A resident with elopement risk, wandering, and poor safety awareness had orders for a Secure care device and was observed near the exit door, and another resident with wandering behaviors was also observed self-propelling near the same door while the alarm continued.
Failure to Prevent Elopement and Investigate Incident: A resident with dementia, hearing loss, wandering behavior, and known elopement risk left the facility through an alarmed stairwell door and then through an unlocked, unalarmed exterior door without staff intervention. Staff did not respond to the alarm, emergency services were not contacted until after the resident was seen on nearby roads, and the nurse’s documentation lacked required details. The DON also reported no police or ambulance information on the resident’s exact location or how she was found.
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