A deficiency was cited for failure to prevent elopement and recurrent falls due to inadequate supervision, unsecured exits, and incomplete care planning. A newly admitted resident assessed as at risk for elopement and wandering had no related interventions on the baseline care plan, despite moderately impaired cognition and psychiatric and seizure diagnoses. This resident later left the building, was found several blocks away after falling and sustaining abrasions, and was subsequently observed at times without the one-on-one supervision that had been ordered, while a dining room exit door and perimeter gate remained unlocked and accessible. Another resident with vascular dementia, muscle weakness, and a history of multiple falls experienced several unwitnessed falls over months, culminating in two right hip fractures requiring surgical repair, yet fall-prevention interventions were not added to the care plan, and staff relied on verbal instructions and vague "close observation" rather than documented, individualized fall-prevention measures.
A resident with intact cognition, independent ADLs, COPD, respiratory failure, and PRN oxygen orders had multiple small portable oxygen cylinders stored unsecured on the floor of their closet, despite a facility policy requiring cylinders to be secured in a designated locked storage area and routinely checked. The care plan included use of a portable oxygen apparatus but lacked interventions addressing the resident’s practice of bringing in and storing portable cylinders from a family member’s home. Staff interviews revealed that a CNA knew cylinders should only be kept in a locked oxygen room, while a housekeeper had seen cylinders in the closet but did not know they were prohibited, and the DON acknowledged prior removals of cylinders from the room without established interventions to prevent recurrence.
A resident with CHF and HTN, assessed as cognitively intact and ambulatory with a walker, was not identified as an elopement risk and was able to leave the building unattended. While a nurse was charting at the nurse’s station, staff discovered the resident had exited through a coded door, walked toward a highway, and approached a stopped semi-truck to ask the driver for a ride home. The resident later stated they waited for the nurse to leave the desk, used the door code, and walked down the road to the highway after becoming upset with a family member. A corporate nurse consultant acknowledged the resident should not have been able to leave the building unsupervised.
A resident with Alzheimer’s disease, dementia, and severely impaired cognition was initially assessed as not being an elopement risk, but later eloped after a lapse in supervision at an exit door. Observations showed the resident generally resting in bed without elopement behaviors and being easily redirected when seen in the hallway. Staff reported they kept close tabs on the resident, but the administrator acknowledged staff should have ensured no resident followed them out an exit, resulting in a deficiency for failure to provide adequate supervision to prevent elopement.
A resident with dementia, moderately impaired cognition (BIMS 9), and a documented history of elopement and prior injury in the community was admitted after hospital records and a family member identified them as an elopement risk. The social worker later reported learning of the elopement history from hospital records and verbally informing nursing staff, but did not document this information or the notification. On the night of the incident, staff last observed the resident during night‑shift rounds around 3:30–4:00 a.m. and discovered the resident missing during early morning hours. A CNA and an LPN searched the building and surrounding area without success, noting the resident’s room window appeared secured with the screen in place and with no clear route of exit identified. The resident was ultimately found in the community near a public school several miles away and was assessed by an LPN on return with no injuries noted.
A resident with COPD, lung cancer, respiratory failure, and other psychiatric diagnoses, who was cognitively intact and used oxygen, repeatedly obtained and used cigarettes in their room despite a facility policy prohibiting smoking materials in resident rooms. Staff and leadership were aware of prior evidence of in-room smoking, including ashes found on the toilet and an incident where the resident hid a cigarette in their pocket, yet smoking assessments continued to rate the resident as safe to smoke with minimal supervision. Ultimately, the resident smoked in their room while on oxygen, causing facial burns, and a lighter was later found under the bed, demonstrating that the facility failed to adequately enforce its smoking policy and supervise the resident to prevent accident hazards.
A resident with dementia, psychosis, diabetes, moderate cognitive impairment (BIMS 12), and a care plan identifying wandering risk had previously left the property multiple times. On the incident day, the resident insisted on leaving after dark, refused redirection attempts by a CNA and safety education by a nurse, became agitated, and signed out. A CNA briefly followed the resident down the street before returning to care for other residents and notifying the nurse. The resident subsequently left unsupervised, was struck by a car, and later died at the hospital. Surveyors found that the facility, which lacked an elopement policy and alert system despite known elopement risk, failed to provide adequate supervision to prevent elopement for this resident.
A resident with heart failure, HTN, severely impaired cognition (BIMS 06), weakness, and knee buckling was identified as high risk for falls based on a fall risk score of 11. Facility policy and the DON’s stated process required fall risk evaluations at admission, quarterly, annually, on re-admission, and with significant change in condition, but no fall risk evaluation was documented for this resident for several months after the initial high-risk score. During this time, the resident’s care plan identified fall risk related to weakness, knee buckling, and HTN, and the resident experienced a fall during transfer. Leadership later acknowledged that a quarterly fall risk evaluation should have been completed but was not.
A resident with Huntington’s disease, anxiety, depression, delusions, and a documented high risk for wandering repeatedly eloped from the facility despite an existing care plan and wandering risk evaluation. The resident left the building on multiple occasions, including episodes where they fell in a field, were found at a hotel, intentionally burned the back of their hand while away, and were located by police at a known drug house and by family at a local business. Staff consistently relied on q15-minute visual checks as the primary intervention after each elopement, did not update the care plan with new interventions, and did not conduct root-cause investigations of the elopements. The DON later acknowledged that the q15-minute checks were not effective, and camera reviews showed discrepancies between staff reports of last contact and the actual time the resident exited the building.
Two residents sustained first- and second-degree burns after spilling excessively hot coffee or tea that had been served without lids and without adherence to the facility’s hot liquid safety policy. One resident with dementia, psychosis, and impaired vision, who could not complete a BIMS interview, was left drinking hot coffee alone without a lid despite a care plan intervention to ensure awareness of hot liquids and provide lids as needed. Another cognitively intact resident with convulsions, reduced mobility, muscle weakness, and tremors treated with propranolol also drank from an unlidded cup and later reported spilling hot tea, resulting in a second-degree burn. Surveyors measured coffee and hot water temperatures well above the policy threshold, and kitchen staff reported they did not temp hot beverages and were unaware of the hot liquid policy.
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