Resident Elopement Due to Inadequate Door Monitoring and Risk Assessment
Summary
A deficiency occurred when a resident who required minimal assistance with ambulation using a front wheel walker was able to exit the facility through an unsupervised, non-alarmed front door without staff knowledge. The facility did not have a system in place to monitor the front door after the receptionist left for the day, and the door could be freely opened from the inside, allowing residents to leave undetected. Staff were observed propping the front door open with a box of gloves to facilitate staff entry, leaving the entrance unsupervised and accessible to residents and unauthorized individuals. Multiple staff interviews confirmed that the front door was not consistently monitored, and there was no alarm system to alert staff if someone exited through it. The resident in question had a medical history including acute myocardial infarction, coronary angioplasty, heart failure, COPD, and psychosis. Despite being assessed as low risk for elopement due to an assumption of non-ambulatory status, therapy records and staff interviews indicated the resident was able to ambulate with minimal assistance using a walker. The resident was last seen in his room in the evening and was later found at a local restaurant approximately one mile away, after which he experienced shortness of breath, was transported to a hospital, and subsequently died from cardiac arrest. The inaccurate assessment of the resident's mobility and elopement risk, as well as the lack of appropriate interventions and monitoring, directly contributed to the resident's ability to leave the facility unnoticed. Additional observations revealed that staff did not respond promptly to exit door alarms, with alarms sounding for several minutes without investigation. Staff interviews indicated confusion about responsibilities for responding to alarms and a lack of clear procedures for monitoring exit doors, especially during times when the front lobby was unsupervised. The facility's policy required identification and care planning for residents at risk of elopement, but this was not followed in the case of the resident who eloped. The combination of inadequate assessment, lack of monitoring systems, and failure to respond to alarms resulted in a serious lapse in resident safety.
Removal Plan
- The Elopement Evaluation for active residents was completed by the Director of Staff Development (DSD), Infection Prevention Nurse (IPN) and Case Manager (CM). Residents identified to be at risk for elopement. The Elopement Evaluation will be completed upon admission, readmission, quarterly, annually, and as needed by the Minimum Data Set Nurse (MDSN)/ Designee. Upon completion of elopement evaluation by the licensed nurse, the Director of Nursing (DON)/Designee will review for accuracy. Resident centered care plans with emphasis on elopement interventions will be reviewed, updated, and completed to ensure resident safety upon completion of the Elopement Evaluation. After completion of Elopement Evaluation, the Licensed Nurse will initiate interventions/measures such as one to one (1:1) monitoring, sitter, hourly rounding, place resident in a supervised area when in wheelchair, re-route resident when attempting to seek exit, engage resident in activities of choice.
- The care plan for residents identified to be at risk for elopement was reviewed and updated by DON/Designee. The care plan interventions included measures such as: hourly rounding, placed in supervised area, redirection / rerouting. Residents placed on 1:1 monitoring for 24 hours and will be evaluated by the Interdisciplinary Team (IDT) for continuation or discontinuation. Residents in the same room were placed on a sitter for 24 hours and will be evaluated by the IDT for continuation/discontinuation.
- The IDT initiated a care plan meeting for residents identified to be at risk for elopement with a follow up call to the resident's representative by the IP Nurse.
- The Maintenance Director checked facility egress doors and tested all audible door alarms for functionality. There were no negative findings identified in all exit doors. Egress tests and checks will be maintained daily for four weeks then weekly thereafter by the Maintenance Director. Exit Door Audit logs will be completed by Maintenance Director /Designee daily. The Administrator will perform validation rounds on door and alarm testing once a week. If the alarm is not working, maintenance will be notified via TELS, Maintenance department will fix and if more time needed, a staff member will be assigned to monitor door until it is fully operational. If a resident is observed attempting to leave using the egress door, staff will redirect and prevent the resident from leaving and notify the Licensed Nurses for further action / interventions.
- The DON/Designee initiated skills competency to licensed nurses on resident admission and elopement with emphasis on identifying risks, prevention, interventions, and door security procedures to ensure all exit doors are attended and checked for resident safety. The DSD/Designee initiated in-service training to Certified Nursing Assistant (CNA) on elopement policy with emphasis on prevention, interventions, monitoring of all exit doors and alarm system, identification of elopement risk residents, location of elopement binders and pink wristbands as elopement identifier. Staff training provided by the DSD/Designee on monitoring all exit doors and ensuring all exit doors are secured and alarm in place. Staff training with emphasis on ensuring all exit doors are secured and an alarm in place: a. The front door will be unlatched, and the alarm will be turned off by the receptionist on duty to allow entrance and exit of facility staff and visitors. b. The front door activity will be monitored by the receptionist on duty. c. The receptionist, before leaving for the day, will inform the licensed nurse to ensure continuity of monitoring of the front door. The licensed nurse will ensure the front door is fully latched, and the alarm is turned on. d. An assigned staff from 3p.m. to 11 p.m., and 11-7 p.m., will monitor the exit doors. The DSD/Designee is responsible for preparing the daily assignment for checking the exit doors that are latched and alarms on. An exit door and alarm monitoring log will be completed by the assigned Nursing staff to document the checking of all doors and alarms as assigned hourly. e. Any licensed nurse on leave will receive training on their next scheduled workday prior to their shift.
- The DON/Regional Clinical Resource initiated an in-service to the nursing staff regarding the updated resident elopement binder which is located at each nurse's station and reception area that has the following information: a. List of residents that are elopement risk b. Guide for staff on steps to take in case of elopement: Refer to Elopement Policy included in the binder as well as the list of the local police and fire department, and nearby acute hospitals in the area. c. Each resident packet includes demographic information which includes a copy of the resident's latest photograph, face sheet, elopement risk identification, most recent elopement evaluation, and updated elopement care plan.
- The DON/Designee is responsible for updating the content of the Elopement Binder for any newly identified and or changes in resident elopement evaluation and plan of care. Any new information, updates or changes with the list of residents in the Elopement Binder will be communicated by the DON / Designee with the nursing staff during the shift huddle and Point Click Care Communication Home Page. A pink wristband will be applied to a resident by the DON/Designee and to be worn by a resident determined to be an elopement risk based on evaluation. The pink wristband will include the resident name, date of birth identification, facility address, and telephone number. The department managers will check out the resident pink wristband during the daily Patient Centered Rounds to ensure wristbands are in place and worn per plan of care. Registered Nurse (RN) Supervisors responsible for checking the wristbands on weekends. If pink wristbands are not in place, Department Managers will notify the DON/Designee for replacement. On weekends, the Registered Nurse Supervisor (RNS) will replace the pink wristbands which are available at Station 1.
- The Medical Director was informed by DON regarding the incident. No new orders were given.
- The Elopement Binder was reviewed and updated by the DSD/Designee and placed at each nursing station and the reception area.
- The DSD/Designee placed pink wristbands to residents as an elopement identifier.
- The Maintenance Director initiated daily checks on all exit doors to ensure they were properly latched and alarms functioning.
- Nursing staff from 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m., shifts. The DSD/ Designee is responsible for preparing the daily assignment for checking the egress doors and alarms of exit doors and if properly latched with alarms on. An exit door and alarm monitoring log will be completed by the assigned Nursing staff to document the checking of exit doors as assigned hourly.
- The facility installed an alarm on the front lobby door, with a key in a red key holder located inside the reception area.
- The receptionist hours were increased, with the expectation to monitor the front door lobby for residents leaving or attempting to leave unattended. In case of receptionist is not available during break, another staff will cover to ensure continuity of monitoring is in place.
- The Administrator and Regional Nurse Consultant provided 1:1 in service training to RNS 1 and reviewed elopement policy with emphasis on accurate assessment of a resident determined to be at risk for elopement which includes reviewing records from GACH, initiating care plan interventions to maintain resident safety and facility's elopement policy and procedures. Inservice and education with the licensed nurses was also initiated regarding accurate assessment and elopement policy with emphasis on accurate assessment of a resident determined to be at risk for elopement which includes reviewing records from GACH, initiating care plan interventions to maintain resident safety and facility's elopement policy and procedures.
- The Administrator will report findings to the Quality Assurance and Performance Improvement (QAPI) Committee on the outcome of resident elopement evaluation and system implementation status update for review and further action as needed.
- The facility's policies and procedures regarding elopement and wandering residents were reviewed by IDT. Interventions such as 1:1 monitoring, providing a sitter, and hourly safety checks as needed.
- The facility revised its facility's new admission decision tree to include questions about history and frequency of wandering and elopement prior to resident admission to the facility. The admissions coordinator will inquire about additional information regarding elopement, history of wandering- and will be discussed with the team: Administrator, DON, and Social Service Director (SSD). DON will audit new admissions daily.
- DSD/Designee will train new hires in wandering, elopement, and resident safety procedures during orientation.
- All findings will be discussed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting for a minimum of three months or until the pattern of compliance is maintained.
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, 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 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 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 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 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 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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
