A resident with dementia, severe cognitive impairment (BIMS 3/15), poor safety awareness, and high elopement risk, who self-propelled rapidly in a wheelchair and wore a wander guard, was inadequately supervised on a secured unit. The resident wheeled to a stairwell exit door, held the fire bar until it released, exited into the stairwell, and fell down a flight of stairs while in the wheelchair. The stairwell door alarm sounded but was not loud enough to be heard by staff in common work areas such as the shower room, dining room, and a nearby office, and individuals in an adjacent medical office, rather than facility staff, reported hearing the alarm and subsequent noise. The resident was found on the stairwell landing with a head injury and was later diagnosed via CT with a subdural hematoma and subarachnoid hemorrhage, demonstrating a breakdown in elopement prevention and supervision systems.
A cognitively impaired resident with dementia and severe BIMS impairment, care planned and ordered to wear a wander guard with regular placement and function checks, eloped from the facility after being last seen in an activity room with a visitor. Staff later could not locate the resident for dinner, and searches were initiated while the resident’s whereabouts were unknown for several hours. Witnesses, including the Activities Director, Receptionist, another resident’s family member, and the visitor, reported that the resident and visitor exited through the main entrance without a wander guard alarm sounding and without use of a door code. The visitor admitted driving the resident to the spouse’s home without notifying staff. EMS and hospital records documented that the resident had been missing for several hours, was confused, could not recall events, and reported severe throat and chest pain, arriving at the hospital with an ankle monitoring device in place. Upon the resident’s return, the facility discarded the original wander guard without testing its functionality and could not provide evidence of consistent monitoring per policy and physician orders, resulting in an Immediate Jeopardy situation.
A resident with Alzheimer’s disease, dementia, severe cognitive impairment, documented exit-seeking behavior, and a care plan identifying high elopement risk and the use of a wander guard was inadequately supervised. Earlier in the day, an LPN observed the resident attempting to open an exit door and redirected the resident, who was later last seen in their room. The resident subsequently exited a secured unit through a stairwell door that only briefly alarmed and was not connected to the wander guard system, descended to a basement level, and left through an exterior door. Because wander guard sensors were only placed at elevators and not at exit doors or stairwells, the resident’s departure went undetected until a Code Orange was called and the elopement protocol initiated, after which staff located the resident off premises and returned the resident to the facility.
A resident with hemiplegia, partial foot amputation, vascular dementia, and total dependence for transfers experienced multiple incidents while using a stand aid, including sliding to the floor, falling backward, and being lowered to the floor when knees buckled. Despite facility policy requiring post-fall rehab screens, no rehab screens were documented after several of these falls, and the rehab director was unaware of the events and the resident’s non-compliance and knee buckling. Later, rehab formally recommended use of a full-body Hoyer lift with two staff for all transfers, but nursing did not update the care plan or the NA assignment sheet, which continued to direct use of a stand aid, and leadership acknowledged that the resident’s changed transfer status was not clearly communicated to caregivers.
Surveyors found that biohazardous waste and sharps were stored in unlocked, unsecured rooms throughout multiple units, including a secured memory care unit, and in a room off the back entrance with the door partially open. Boxes labeled as infectious or biohazard waste were overflowing with sharps containers and red biohazard bags, with some sharps containers open and needles and IV lines with visible blood exposed, while residents were observed moving near these areas. Staff, including the Administrator, DNS, and Assistant Maintenance Director, acknowledged that the rooms were unlocked, that biohazardous waste remained on the units, and that the contracted waste removal company had stopped pickups due to non-payment, with no evidence of proper biohazard disposal for an extended period.
A resident with bipolar disorder and impaired safety awareness was identified as an elopement risk after an elopement attempt and was ordered to wear a wanderguard on the right arm with staff checks each shift. Surveyors later observed the device was not on the resident, an LPN confirmed it was missing, and a CNA reported the DON had removed it from the unit, while the DON said she thought it was an extra device. The record did not show additional interventions after the resident removed the wanderguard.
A resident with a history of falls and mobility limitations exited the facility unsupervised during severe weather, after previously demonstrating attempts to leave. The care plan was not updated to address wandering or elopement risk, and staff were unaware of the resident's absence until the individual was found outside with frostbite and injuries, requiring hospitalization. The facility failed to provide adequate supervision and did not revise the care plan following earlier incidents.
A resident with a history of smoking and falls, while on oxygen therapy, was able to use a personal lighter in their room, resulting in the ignition of oxygen tubing and a minor fire that damaged the floor and equipment. The facility was aware of the resident's risk factors but did not provide evidence of adequate supervision or environmental safeguards to prevent this accident.
Unlocked Treatment Cart and Missing Smoking Assessments: A treatment cart on a secured unit was left unlocked and unattended while it contained treatment meds and clean razors, with two cognitively impaired residents observed nearby in the hallways. The facility also lacked required quarterly smoking capability evaluations for a resident who wished to smoke and remained on the smoker list, and the DNS acknowledged the missing re-evaluations.
Heating Units Blocked by Recliners: Surveyors found that recliners in two resident rooms were positioned too close to fixed installed heating units, with one recliner about 2 inches from the unit and the other also failing to maintain the required 8-inch clearance. A resident with intact cognition stated the recliner had been in the same spot for at least a year, and the Maintenance Director acknowledged the clearance issue.
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