Failure to Supervise Exit-Seeking Resident Leads to Elopement from Secure Memory Unit
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe, secure environment for a cognitively impaired resident on a memory care unit, resulting in an elopement. The resident was admitted with dementia with behavioral disturbance, cognitive communication deficit, anxiety, and major depressive disorder, and hospital records indicated the need for a secured, locked unit due to impaired safety decisions and poor safety awareness. On admission, the facility’s elopement/wandering risk evaluation scored the resident as a moderate elopement risk, and the admission MDS showed a BIMS score of five, indicating severe cognitive impairment. The resident’s care plan, initiated shortly after admission and later revised, included goals and interventions to maintain safety on the secure unit, including supervision while on the unit and provision of activities of interest with redirection as needed. In the days leading up to the incident, progress notes documented escalating behaviors and clear exit-seeking. Notes from several days before the elopement described the resident as having behavioral issues, constantly stating a desire to go home, yelling out for God to get her out, and repeatedly expressing a desire to leave. Staff interviews further confirmed that the resident frequently packed a suitcase, made statements about wanting to go home, pushed on exit doors, and watched the doors to see if someone would go out. On the day of the elopement, staff reported the resident was antsy, wanted to get out, and was not redirectable, with social services noting that the resident insisted she needed to get to her dying mother. Despite these known behaviors and documented risks, the resident was placed in a room directly catty-corner to an exit door on the secure unit, and there is no indication in the report that enhanced supervision such as 1:1 monitoring was consistently implemented at the time of the incident. On the evening of the elopement, staff on the women’s memory care unit consisted of one LPN and two CNAs for 16 residents, and all three staff members reported being occupied with other resident care tasks when the alarm sounded. One CNA reported hearing the alarm, going to the exit door, seeing another resident in a wheelchair, moving that resident, and, along with the LPN and another CNA, checking the courtyard and not seeing anyone before the LPN turned off the alarm. Another CNA stated she saw the eloping resident at the exit door when the alarm went off, moved her to the dining room, and then returned to provide a shower to another resident, noting that the door did not lock right away and that no one was actively looking for the resident later. The LPN reported responding from the men’s secure unit when the alarm sounded, checking the courtyard and resident rooms per policy, and stated he did not realize the resident was missing until a law enforcement officer arrived and asked about her. The resident was able to exit the building through the alarmed exit door and then leave the courtyard through a deteriorated wooden gate connected to the privacy fence. The maintenance director later acknowledged that the gate’s wood boards were beginning to deteriorate before the incident and that the resident was able to push through the boards and then place them back, securing the gate with empty plant pots on the opposite side, which led staff to believe the gate was secure when checked. The resident reported that on the night she left, both exit doors near her room opened, that the wood gate was faulty and allowed her to get through, and that she ran to a nearby park where she sat on a bench and told a couple about her escape. Concerned citizens at the park called 911, and a sheriff’s officer responded, found the resident, and then went to the facility, where staff initially stated the resident was in her room and were unaware she had left until they checked and found her missing. The officer reported that no staff member told him they were looking for or missing a resident, and the resident herself stated she was unhappy in the facility, did not feel she belonged there, and would leave again if able. The facility’s own elopement and wandering policy stated that residents at risk for elopement were to receive adequate supervision to prevent accidents, that alarms were not a replacement for necessary supervision, and that staff were to respond to alarms in a timely manner. The policy also required a systematic approach to monitoring and managing residents at risk for elopement, including identification and assessment of risk, implementation of interventions to reduce hazards and risks, and monitoring and modifying interventions as needed, with interventions added to the care plan and communicated to appropriate staff. Despite this, staff interviews revealed that at the time of the elopement, all assigned staff were engaged in other resident care tasks, could not provide supervision or diversional activities as outlined in the care plan, and did not recognize or report the resident as missing until notified by law enforcement. The combination of the resident’s known exit-seeking behavior, placement in a room adjacent to an exit door, a defective courtyard gate, and staff being occupied with other tasks when the alarm sounded led to the resident leaving the secure unit and the facility without staff awareness, resulting in the identified deficiency under F689 for failure to ensure adequate supervision and a hazard-free environment.
Removal Plan
- Conduct elopement drills once per shift to ensure staff comprehension of the elopement drill process.
- Complete a 100% audit of door and lock evaluations with no negative findings.
- Complete 100% elopement evaluations.
- Provide 100% staff education (including contract staff) on the Elopement policy/procedure and appropriate resident supervision.
- Initiate an investigation of the incident, including staff interviews and a root cause analysis.
- Repair the defective courtyard gate by facility staff and a licensed contractor.
- Inspect all doors, locks, and gates throughout the facility to ensure proper functioning.
- Add additional interventions to the resident’s care plan: increased supervision, q15-minute checks for 72 hours, and review of medications and labs.
- Adjust the exit door on the Memory Care Unit to prevent delayed egress.
- Review the Elopement Policy by the IDT to include individualized interventions for residents at risk for elopement.
- Audit new admissions weekly for 3 months to ensure elopement risk and interventions are in place.
- Complete elopement risk assessments on all residents.
- Educate MDS/Social Services on completing elopement evaluations, implementing interventions based on findings (including supervision/observation), and the necessity of staff availability and timely alarm response.
- Hold an Ad-Hoc QAPI meeting with leadership/IDT members to review the plan and findings.
- Forward elopement assessment audits to the Executive Director for QAPI Committee review monthly for at least 3 months to ensure ongoing compliance.
- Hold QAPI meetings monthly.
- Correct any deficient practices identified through monitoring immediately and report/review them through the QAPI Committee until ongoing compliance is achieved.
- Complete elopement drills each shift for 1 day and monthly ongoing.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility failed to keep the environment free of accident hazards when a resident’s room contained an unattended shaving razor on the sink and additional razors in a nightstand, despite leadership stating razors were not permitted in resident rooms. An LPN disposed of unused lancets in regular trash instead of a sharps container, contrary to acknowledged policy. On two occasions, an unattended housekeeping cart on an upper floor had germicidal wipes left on top and easily accessible, even though housekeeping leadership and staff stated that chemicals and disinfectant wipes were to be kept locked in the cart for safety.
A resident with severe cognitive impairment, dementia with behavioral disturbances, and fall risk interventions in place was transferred by staff using methods that did not match the care plan and Kardex. Staff used a transfer belt for some transfers, then later used a Hoyer lift from mattresses on the floor to a wheelchair, but used a green sling even though the resident required a yellow sling based on weight. The RN, LPN, DON, and PT verified the resident’s transfer status and sling instructions were not updated to reflect current needs.
A resident with severe cognitive impairment, dementia, a history of falls, and dependence on staff for transfers was observed using a lift reclining chair even though the care plan and physical device review did not identify that device. Therapy staff lowered the chair and placed the remote next to the call light on the resident’s lap, and staff stated they were not aware of any formal assessment for safe use of the lift chair. The DON stated the resident should have had an assessment to determine whether she was safe to have the lift chair.
A resident with nicotine dependence was care planned as a smoker who could go out to smoke at designated times or with family, with an intervention that a smoking evaluation be completed quarterly. The last documented smoking safety evaluation showed the resident could safely smoke with supervision, but no additional evaluations were completed for several months, contrary to facility policy requiring smoking assessments at admission, readmission, with significant change, and quarterly by a licensed nurse, even though the resident continued to smoke under staff and family supervision in the courtyard.
Failure to supervise smokers and secure smoking materials. Surveyors found that 27 smokers were not adequately monitored and that residents were able to keep cigarettes and lighters in their possession despite care plan directions to return them after smoking. One resident with severe cognitive impairment, dementia, schizophrenia, and continuous oxygen use was observed with cigarettes and a lighter while on oxygen, and staff confirmed she was an unsafe smoker requiring direct supervision.
Code Alert System Failed to Prevent Resident Elopement: The facility failed to keep the code alert system functioning as intended and did not follow the manufacturer’s weekly testing and inspection guidance. Two residents with significant cognitive impairment were able to get through the main doors, and one resident exited the building before staff followed outside. The report also states that multiple residents with code alert devices did not have adequate elopement or wandering assessments and care plan interventions, and several attempts to leave were not documented in the record.
Failure to Control Razors, Sharps, and Chemical Wipes Creating Accident Hazards
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and safe handling of potentially hazardous items. On one floor, a shaving razor was observed on the sink in a resident’s room. When questioned, the resident stated the razor on the sink was not his and showed the surveyor separate razors he kept in his nightstand. The resident’s record showed admission with malignant neoplasm of overlapping sites of the bladder and care plans for ADL self-care deficits related to activity intolerance, generalized muscle weakness, bladder cancer, and a history of gross hematuria, with interventions including encouraging and assisting with bathing, personal hygiene, and oral care. Facility leadership, including the ADON, Administrator/Risk Manager, and DON, stated that residents were not allowed to keep shaving razors in their rooms and that razors were to be kept in the supply room. Additional observations showed that staff did not consistently follow safe disposal practices for sharps and did not secure chemical products as required by facility policy. An LPN performing a blood glucose check discarded unused lancets into the medication cart trash instead of a sharps container, despite acknowledging that lancets were to be disposed of in a sharps-resistant container. On two separate observations, a housekeeping cart on the second floor was left unattended with a container of germicidal wipes placed on top of the cart and easily accessible. Corporate housekeeping staff and the Housekeeping Director stated that all chemicals that could harm residents should be locked in the cart’s compartment, and housekeeping staff reported that disinfectant wipes and cleaning supplies were to be kept locked in the cart for resident safety. The facility’s written “Nursing Home Accident Prevention and Safety Policy” stated a commitment to maintaining a safe, hazard-free environment and identifying and correcting safety risks promptly.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. The facility continues to ensure that the resident environment remains free of accident hazards as possible. IMMEDIATE CORRECTIVE ACTION Resident #29 was not adversely affected by the alleged deficient practice. Razor was immediately removed and disposed of from resident's room by nurse on 5/11/26. Germicidal wipes were immediately secured in a locked housekeeping cart on 5/11/26. Staff E was provided with 1:1 education by the Director of Nursing regarding the importance of providing an environment free from hazards and accidents with emphasis on keeping hazardous items like razor secured on 5/11/26. Staff G was provided with 1 to 1 education by House Keeping Director regarding ensuring that all housekeeping chemical products are secured in a locked housekeeping cart when not in use on 5/12/2026. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. The Director of Nursing and/ designee conducted a facility-wide observation audit to ensure that hazardous items are locked and secured and that staff are disposing of Sharps in a Sharp Resistant Container on 05/15/2026. The Housekeeping Director conducted a facility-wide observation on 5/15/2026 to ensure that all housekeeping chemical products were secured and locked inside the housekeeping cart when not in use. No residents were adversely affected by the alleged deficient practice. SYSTEMATIC CHANGES Director of Nursing initiated ongoing in-service education with staff on standards of maintaining an environment free from hazards/accidents with emphasis on keeping hazardous items like razor secured and properly disposing of sharps in sharps resistant container on 5/20/26. The Housekeeping Director and/or designee initiated ongoing in-service education on standards of maintaining an environment free from hazards/accidents with emphasis on keeping housekeeping chemical products secured and locked in a housekeeping cart when not in use on 5/20/2026. MONITORING The Director of Nursing and/or designee will conduct random observation audits to ensure that hazardous items are locked and secured and sharps are disposed in sharps resistant container weekly for 3 months. The Housekeeping Director and/or designee will conduct random observation audits to ensure that housekeeping chemical products are secured and locked in a housekeeping cart weekly for 3 months. The Director of Nursing, Housekeeping Director and/or designee will report findings of observation/audits to the quality assurance committee monthly for 3 months to ensure continued substantial compliance is achieved and maintained.
Failure to Follow Transfer and Sling Size Interventions
Penalty
Summary
The facility failed to ensure staff followed fall risk interventions for one resident identified as at risk for falls. The resident had severe cognitive impairment, delusions, behaviors directed at others, dementia with behavioral disturbances, anxiety, an affective disorder, diabetes, and hearing loss. The resident’s care plan and Kardex identified the resident as a fall risk and stated the resident was independent for transfers, while also noting that if a Hoyer transfer was required, a yellow/medium sling was to be used. During observation, nursing assistants transferred the resident from a wheelchair to the toilet using a transfer belt, then later transferred the resident from the wheelchair to mattresses on the floor using a transfer belt and two staff members. Staff stated they normally used a Hoyer lift to lift the resident from the mattresses on the floor, but the resident’s Kardex did not identify the mattresses on the floor or clarify when a Hoyer should be used for transfers. Staff also stated the resident was not independent with transfers and required one to two staff for wheelchair-to-toilet transfers and two staff with a Hoyer for transfers to and from the mattresses on the floor. On a later observation, two nursing assistants used a Hoyer lift to transfer the resident from the mattresses on the floor to a wheelchair, but used a green sling even though the resident weighed 155 pounds and the manufacturer’s chart indicated a yellow sling was required. Staff stated the green sling was too big for the resident and that the correct sling size was important for safety. The RN, LPN, DON, and PT all verified that the resident’s care plan and Kardex were not revised to reflect the resident’s current transfer abilities and the correct sling size and transfer method for the resident’s current setup.
Failure to Assess Safe Use of Lift Reclining Chair
Penalty
Summary
The facility failed to ensure a resident was safe to have a lift reclining chair. The resident had severe cognitive impairment, lower extremity impairment on one side of the body, a history of falls, dependence on staff for transfers, and diagnoses including dementia, disorientation, anxiety, muscle weakness, and a right pubis fracture. The resident’s care plan identified high fall risk related to impaired mobility, confusion, and dementia, and directed staff to keep the call light within reach and encourage use of it. The care plan also stated the resident required two staff to assist with transfers using a standing lift as needed, but it did not identify use of a lift reclining chair. The physical device review also did not identify an electric recliner chair or other lift type reclining chair. During observation, the resident was transferred into the lift chair by therapy staff, who lowered it from an upright position to a seated and then reclining position. The remote for the lift chair and the call light were both placed on the resident’s lap next to each other. The PTA stated she was not aware of any assessment for safe use of the lift chairs, and nursing and therapy staff stated they were not aware of any formal lift chair assessment for the resident. The DON stated therapy worked with residents who had lift chairs and was not aware of any formal assessment, and later stated the resident should have had an assessment completed to determine if she was safe to have a lift chair. The DON also stated the resident was cognitively impaired and could accidentally use the lift chair remote when intending to push the call light.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
The facility failed to ensure resident safety related to smoking by not completing required smoking safety assessments at the prescribed frequency for one resident. A resident with a diagnosis that included nicotine dependence was observed smoking in the courtyard with his daughter present, and later in the presence of Activities staff who remained outside with the residents while they smoked. The resident’s care plan, dated 2/4/25, identified him as a smoker who could go out to smoke at designated times or with family and specified that a smoking evaluation would be completed quarterly. Record review showed the most recent Smoking Safety Evaluation had been completed on 11/6/24 and indicated the resident could safely smoke with supervision, but no further evaluations were completed until 4/30/26, despite facility policy requiring smoking assessments upon admission, readmission, with significant change, and quarterly by a licensed nurse.
Failure to Supervise Smokers and Secure Smoking Materials
Penalty
Summary
The facility failed to adequately supervise 27 identified smokers and failed to secure resident smoking materials, including lighters and cigarettes. Surveyors found that the facility’s smoking policy required smoking-related privileges, restrictions, and concerns to be documented in the care plan and communicated to personnel, and required residents with restricted smoking privileges to be monitored under direct supervision while smoking. Resident #15 was observed sitting up in bed with oxygen in use, and later was observed on the smoking patio sitting in a wheelchair with a plastic bag containing cigarettes and a lighter in her lap. Staff confirmed she was identified as an unsafe smoker and required a smoking apron while smoking. Her record showed severe cognitive impairment with a BIMS score of 6, diagnoses including dementia and schizophrenia, and continuous oxygen at 2 liters per minute via nasal cannula for COPD. Review of the records for all 27 smokers showed care plan interventions requiring them to return smoking materials to the Activities Department after re-entering the building from the smoking patio. Interviews with the Activity Director, LPN, MDS staff, CNA, DON, Administrator, and Medical Director showed conflicting descriptions of where smoking materials were kept, but multiple staff acknowledged that residents kept cigarettes and lighters in their possession and that residents were expected to turn them in after smoking. The Medical Director stated residents were not permitted to keep cigarettes or lighters and that residents with low BIMS scores or those receiving oxygen should not have access to smoking materials.
Code Alert System Failed to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure the code alert system used for residents at risk for elopement was functioning properly and failed to follow the manufacturer’s recommendations for weekly testing and inspection. The report states that the immediate jeopardy began when R12 was able to exit the building after the main entrance code alert system malfunctioned, and that R19 was also able to get through the main doors because the doors did not lock as required by the system. The manufacturer’s binder in the facility called for weekly testing of the code alert units, regular testing of each detection zone, and quarterly service inspections, but the facility’s logs showed the doors were being tested monthly instead of weekly. R19 was severely cognitively impaired with Alzheimer’s disease. The resident’s assessment identified low elopement risk, and the care plan lacked interventions for elopement and wandering. During observation, R19 wheeled to the main entrance, went through the first door into the vestibule, and the alarm sounded, but the door did not lock. A nursing assistant responded and redirected R19 back to the central TV area. The resident’s progress note did not include the attempt to leave the building. R12 was severely cognitively impaired with non-Alzheimer’s dementia and anxiety. The resident had repeated attempts to leave the facility, but the care plan lacked elopement and wandering interventions, and the most recent assessment also identified low elopement risk with the door alarm band not selected. During observations, R12 repeatedly approached the main entrance, triggered the alarm, and was able to get through the first door into the vestibule; on one occasion R12 exited the building before being followed outside by staff. The report also states that R12’s record lacked documentation of the successful exit and other attempts to leave. In addition, the facility failed to adequately assess and develop care plans for multiple other residents assigned code alert devices, including residents with severe or moderate cognitive impairment and diagnoses such as dementia and Alzheimer’s disease, whose care plans did not include elopement or wandering interventions or, in some cases, the location of the device.
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