Citations in Mississippi
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Mississippi.
Statistics for Mississippi (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Mississippi
Several residents were not provided with sufficient incontinence briefs during the night shift, leading staff to use pads and bedsheets as substitutes when supplies ran out. Multiple staff, including CNAs and LPNs, reported not having access to additional briefs overnight, and residents expressed discomfort and distress over the practice. Facility policy required residents to be treated with dignity and respect, but the practice of limiting briefs and not consulting residents about their preferences was confirmed by staff and the DON.
The facility failed to follow its abuse prevention policy by not removing a CNA from resident care after multiple abuse allegations, and did not conduct a timely or thorough investigation. Two residents with significant medical and cognitive needs reported rough and intimidating treatment by the CNA, but the CNA continued to provide care to them. Nursing staff acknowledged the complaints but did not ensure the CNA was reassigned, and family members were not updated on the investigation.
A male resident with a history of sexually inappropriate behaviors was not placed under supervision or subject to care plan interventions, despite prior incidents. This led to two female residents with severe cognitive impairment being inappropriately touched in the day room on separate occasions. Staff failed to communicate the initial incident, resulting in the resident being left unsupervised and able to reoffend before one-to-one observation was implemented.
A facility failed to update and implement a care plan for a resident with a history of sexually inappropriate behaviors, despite documented incidents and psychiatric evaluation indicating severe cognitive impairment and poor judgment. The resident was left unsupervised after an initial incident and subsequently inappropriately touched two other cognitively impaired residents in the day room. Staff interviews confirmed the care plan was not updated until after these incidents occurred.
A resident with moderate cognitive impairment and hemiplegia was subjected to abuse when a nurse aide pulled the resident from a seated position onto the floor, verbally berated the resident, and sprayed an aerosol substance on the resident's lower body. Multiple staff and the resident confirmed the aide's actions, which resulted in the resident experiencing fear, distress, and compromised dignity.
A resident with moderate cognitive impairment was found on the floor after an altercation with a nurse aide, who was reported by witnesses to have pulled a pillow from under the resident and sprayed them with an aerosol substance. Multiple staff provided written witness statements, but these were not included in the facility's abuse investigation documentation. The administrator dismissed the allegation due to conflicting accounts and lack of proof of intent, despite evidence from several witnesses.
A nurse performed PEG tube care for a resident with hemiplegia, hemiparesis, and dysphagia without wearing a gown, contrary to facility policy and posted EBP signage requiring gown and gloves for high-contact device care. Interviews with staff and review of records confirmed that the resident was at high risk for infection and that proper EBP was not followed during the observed care event.
A resident with moderate cognitive impairment and a history of inappropriate sexual behaviors was not provided with increased supervision or monitoring, despite escalating incidents and medication changes. This lack of proactive measures led to an incident where the resident inappropriately touched another resident who was severely cognitively impaired and unable to protect herself. Staff interviews confirmed that no additional monitoring was implemented, and the deficiency was acknowledged by facility leadership.
Staff failed to follow abuse prevention and investigation policy when a resident was physically blocked by an RN during an attempt to bring cigarettes into the facility. Both an LPN and a CNA witnessed the incident but did not report it to facility leadership, resulting in the event not being investigated as required by policy.
Two residents experienced significant medication errors due to failures in medication reconciliation and administration. One resident did not receive prescribed antibiotic therapy after a hospital discharge order was incorrectly transcribed, leading to missed doses and subsequent rehospitalization for wound infection. Another resident received a double dose of antihypertensive medications when two LPNs administered the same medications without proper EMAR documentation, requiring close monitoring and IV fluids.
Failure to Provide Adequate Incontinent Care Supplies and Maintain Resident Dignity
Penalty
Summary
The facility failed to provide adequate incontinent care supplies during the night shift for four of five sampled residents, resulting in residents not being treated with dignity and respect. Staff interviews revealed that residents were only given a set number of incontinence briefs each morning, typically six for a 24-hour period, and if these ran out before the next distribution, staff were instructed to 'bridge' residents using pads and bedsheets instead of briefs. Multiple staff members, including CNAs and LPNs, confirmed that they did not have access to additional briefs during the night shift, and that the environmental room where extra briefs were supposed to be stored was found to be empty during the surveyor's observation. Residents directly affected by this practice expressed discomfort and distress. One resident, who was severely cognitively impaired and frequently incontinent, was observed lying in bed with only a sheet covering his lower body and no brief on. Another resident, moderately cognitively impaired and always incontinent of bowel, reported that staff did not ask for her preference and simply used a sheet when briefs ran out, which she disliked but felt powerless to contest. A cognitively intact resident with a suprapubic catheter and bowel incontinence stated that briefs often ran out and staff would search other rooms for supplies, but sometimes resorted to using sheets, which he found unacceptable. Another cognitively intact resident with bowel and bladder incontinence described feeling anxious and stressed at night due to the lack of briefs, stating that she tried not to move to avoid urinating on a bedsheet and that the situation caused her mental anguish. Facility policy review indicated that residents have the right to receive adequate and appropriate health care and to be treated with dignity and respect. However, interviews with staff and the DON confirmed that the practice of limiting briefs and using 'open air' or bridging was implemented without consulting residents about their preferences. The DON acknowledged that non-cognitive residents were not provided briefs at night and that there were no extra briefs available in the locked room on the morning of the survey. Housekeeping and supervisory staff also confirmed the practice of distributing a fixed number of briefs and the lack of access to additional supplies during the night shift.
Failure to Remove CNA and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse prevention policy by not removing a Certified Nursing Assistant (CNA) from resident care following multiple allegations of potential abuse. Despite reports from residents and their family members that the CNA was rough, mean, and had allegedly hit or intimidated a resident, the CNA continued to provide care to the same residents. Interviews revealed that both residents and their representatives reported these concerns to nursing staff, but the CNA was not removed from their assignments, and continued to enter the rooms of the affected residents. The investigation into the allegations was neither timely nor complete. Family members and residents reported that after making complaints to the nursing staff, there was no follow-up or communication from the facility regarding the status of the investigation or any actions taken. The LPN Charge Nurse acknowledged her responsibility to remove the CNA from resident care during an allegation of abuse, but confirmed that the CNA continued to have contact with the residents involved. The Director of Nursing (DON) also indicated that the situation should have been addressed more thoroughly, especially since multiple residents had raised concerns about the same CNA. The residents involved had significant medical conditions and cognitive impairments, as indicated by their diagnoses and Brief Interview Mental Scores (BIMS). One resident expressed fear and distress due to the CNA's continued presence, stating she could not sleep while the CNA was in the room. Documentation and interviews confirmed that the facility did not implement interventions to protect residents from further potential abuse, nor did it ensure proper reporting and investigation procedures were followed as outlined in its abuse prevention policy.
Failure to Protect Residents from Sexual Abuse Due to Lack of Supervision and Communication
Penalty
Summary
The facility failed to protect residents from sexual abuse by not implementing immediate supervision or restrictions for a male resident with a known history of sexually inappropriate behaviors. Despite prior incidents of sexual comments and inappropriate conduct toward staff, no care plan interventions or increased supervision were put in place before the resident inappropriately touched two female residents in the day room. The first incident occurred when the male resident touched the breast of a female resident, which was witnessed by a janitor who separated the residents and notified an LPN. After the initial incident, the LPN escorted the male resident to his room but left him unsupervised while reporting the event to the DON. During this time, another CNA, unaware of the incident, assisted the male resident back to the day room, where he subsequently inappropriately touched the breast of a second female resident. Staff interviews confirmed that there was a lack of communication regarding the initial incident, and the male resident was not placed on one-to-one supervision until after the second incident occurred. The male resident involved had a history of cognitive impairment, poor judgment, and previous sexually inappropriate verbal behaviors, as documented in his medical and psychiatric records. Both female residents who were touched also had severe cognitive impairments. The facility's failure to implement protective supervision and communicate the risk to all staff resulted in two residents experiencing non-consensual sexual contact and placed other vulnerable residents at risk.
Removal Plan
- Hold QA meeting to review Abuse Policy and Care plan policies with all disciplines.
- Start 1-1 observation by DON and ADON when an incident is reported. Assign this to the scheduled Certified Nursing Assistant (CNA).
- Conduct in-services on Abuse and Identifying Sexual Abuse and Capacity to Consent by Staff Development Nurse and the Administrator. Train all staff that if staff witnesses abuse, the one who perpetrates or initiates abusive behavior cannot remain in contact with other residents. Take them with you to a supervisor or another employee must remain with them until a decision is made as to what needs to be done. Do not allow staff to work until in-serviced.
- Discipline and educate LPN #1 on 1-1 supervision when there is an abuse allegation.
- Educate CNA #1 on proper undergarment placement for Resident #2.
- Update Care Plans for all Residents involved and review all residents with behaviors and their care plans.
- Conduct body audits on Resident #2 and Resident #3.
- Initiate hourly checks on Resident #2 and Resident #3.
- Send referrals to multiple Geri-psych units and other facilities for Resident #1.
- Assign 1-1 observation of Resident #1 to the scheduled Certified Nursing Assistant (CNA). Use Post Event Hourly Monitoring Form.
- Review Care Plans on Residents with behaviors weekly for 4 weeks, monthly for 3 months, and then quarterly. Social Services Director and Care Plan Nurse will be responsible for reviewing and addressing in QA.
Failure to Develop and Implement Care Plan for Sexually Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing sexually inappropriate behaviors for a resident with a known history of such behaviors. Despite documented incidents of sexually inappropriate comments and actions, including a prior event where the resident asked to see a staff member's breasts and a psychiatric evaluation noting sexually impulsive behavior, the care plan was not updated to include individualized interventions, monitoring instructions, or staff guidance. The resident's cognitive status was severely impaired, as indicated by a Brief Interview for Mental Status score of 6 and psychiatric notes describing poor judgment, impaired decision-making, and confusion. On the day of the incident, the resident inappropriately touched the breasts of two female residents in the day room. After the first incident was witnessed by a staff member, the resident was taken to his room but left unsupervised. Another staff member, unaware of the incident, assisted the resident back to the day room, where a second incident occurred. Both female residents involved had severe cognitive impairment and required staff assessment for mental status. The facility had prior knowledge of the resident's sexually inappropriate behaviors but did not implement immediate supervision or restrictions to protect other residents. Interviews with facility staff confirmed that the care plan was not updated until after the incidents occurred, despite escalating behaviors and psychiatric recommendations. The lack of timely and effective care planning and supervision resulted in two residents experiencing non-consensual sexual contact and placed other vulnerable residents at risk.
Removal Plan
- Hold QA meeting to review Abuse Policy and Care plan policies with all disciplines.
- Start 1-1 observation by DON and ADON when an incident is reported, assigned to the scheduled Certified Nursing Assistant (CNA).
- Conduct in-services on Abuse, Identifying Sexual Abuse, and Capacity to Consent by Staff Development Nurse and Administrator. Train all staff that if staff witnesses abuse, the perpetrator or initiator cannot remain in contact with other residents and must be taken to a supervisor or another employee must remain with them until a decision is made. Do not allow staff to work until in-serviced.
- Discipline and educate LPN on 1-1 supervision when there is an abuse allegation.
- Educate CNA on proper undergarment placement for Resident.
- Update Care Plans for all Residents involved and review all residents with behaviors and their care plans.
- Conduct body audits on Residents.
- Initiate hourly checks on Residents.
- Send referrals to multiple Geri-psych units and other facilities for Resident.
- Assign 1-1 observation of Resident to the scheduled Certified Nursing Assistant (CNA) and use Post Event Hourly Monitoring Form.
- Review Care Plans on Residents with behaviors weekly for 4 weeks, monthly for 3 months, and then quarterly. Social Services Director and Care Plan Nurse will be responsible for reviewing and addressing in QA.
Resident Subjected to Physical and Verbal Abuse by Staff Member
Penalty
Summary
A deficiency occurred when a staff member, Nurse Aide (NA) #1, engaged in abusive conduct toward a resident with moderate cognitive impairment and a history of hemiplegia and hypertensive urgency. The incident involved the aide pulling the resident from a seated position onto the floor, verbally berating him, and spraying him with an aerosol substance. Multiple staff and resident interviews confirmed that the aide entered the resident's room, expressed frustration, and proceeded to remove a pillow from under the resident, causing him to fall. While the resident was on the floor, the aide continued to yell at him to get up and sprayed his lower body with an aerosol spray, which was believed to be disinfectant or air freshener. Witnesses, including housekeeping staff and another CNA, reported hearing the resident scream for help and observed the aide laughing and continuing the abusive behavior. The resident expressed fear for his life and distress over the incident, stating he was shaken and scared by the aide's actions. Staff members who entered the room found the resident on the floor and the aide sitting in a chair, laughing, and continuing to spray the resident and throw his belongings into the garbage can. Despite conflicting accounts from some staff regarding the intent and details of the incident, the totality of evidence from interviews and witness statements substantiated that abuse did occur. The resident experienced actual psychosocial harm, including fear, distress, and compromised dignity as a result of the aide's actions. The facility's failure to protect the resident from all forms of abuse constituted a violation of regulatory requirements.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident. The incident occurred when staff responded to the resident screaming for help and found the resident on the floor after an altercation with a nurse aide. The resident reported that the nurse aide pulled a pillow from under them, causing them to fall, and then sprayed them with disinfectant spray. Witness statements from housekeeping and other staff corroborated that the nurse aide was laughing, yelling at the resident, and spraying their legs with an aerosol substance. Multiple staff members wrote witness statements and submitted them to administration. Despite these accounts, the facility's abuse investigation did not include the witness statements from the staff in the documentation. The administrator determined the allegation could not be substantiated due to an inability to prove intent and conflicting accounts, but acknowledged that the determination was not supported by the totality of evidence. The resident involved had a history of moderate cognitive impairment and other medical conditions. The facility's actions did not align with its policy to thoroughly investigate all alleged violations.
Failure to Implement Enhanced Barrier Precautions During PEG Tube Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with its own policy and current infection control standards during percutaneous endoscopic gastrostomy (PEG) tube care for one resident. During an observed care event, a registered nurse performed PEG tube care without donning a gown, despite facility policy and posted signage requiring both gown and gloves for high-contact care activities involving indwelling medical devices such as feeding tubes. Interviews with the nurse, the infection preventionist, and the director of nursing confirmed that a gown should have been worn during this procedure to protect the resident from potential contamination from the staff member's uniform. The resident involved had a history of hemiplegia and hemiparesis following a cerebral infarction, as well as dysphagia, and was assessed as having moderate cognitive impairment. Physician orders required daily cleaning and dressing of the PEG tube site. Facility records and staff interviews indicated that the resident was at high risk for infection due to the presence of the PEG tube, and that failure to use a gown during care could result in the transfer of organisms from staff to the resident.
Failure to Provide Adequate Supervision for Resident with Behavioral Disturbances
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for a resident with a history of behavioral disturbances, including inappropriate sexual behaviors. The resident, who was moderately cognitively impaired and diagnosed with dementia, bipolar disorder, and Alzheimer's disease, exhibited escalating inappropriate behaviors over a documented period. Despite an increase in medication dosage and multiple psychiatric evaluations, there was no documentation or implementation of increased supervision or monitoring for this resident. Staff interviews confirmed awareness of the resident's behaviors but revealed that no additional monitoring measures were put in place. An incident occurred in which the resident attempted to touch another resident, who was severely cognitively impaired and unable to protect herself, inappropriately. Staff intervened immediately during the incident, but records and interviews indicated that the facility had not taken proactive steps to prevent such events by increasing supervision. The Director of Nursing and other staff acknowledged the lack of documentation and implementation of increased monitoring, despite the resident's ongoing behavioral issues.
Failure to Report and Investigate Resident Incident Involving Staff
Penalty
Summary
Facility staff failed to implement the abuse prevention and investigation policy when an incident occurred involving a resident and a registered nurse. The incident involved the nurse physically blocking the resident from entering the building and attempting to take a bag containing cigarettes from him, resulting in a tussle at the doorway and the resident's arm becoming caught. The resident, who was cognitively intact and had a history of hemiplegia and hemiparesis following cerebral infarction, reported the incident during an interview. Two staff members, an LPN and a CNA, witnessed the event but did not document or report it to facility leadership as required by policy. The facility's policy mandates immediate reporting of any incident involving suspicion or allegation of mistreatment, exploitation, neglect, or abuse to the Administrator. Despite this, neither the LPN nor the CNA notified the Director of Nursing, Assistant Director of Nursing, or Administrator about the incident. The Director of Nursing and Administrator both confirmed they were not informed and stated that an investigation would have been initiated had they been notified. The failure to report and investigate the incident constituted a breach of the facility's abuse prevention and investigation policy.
Medication Reconciliation and Administration Errors Result in Missed Antibiotic Therapy and Duplicate Antihypertensive Dosing
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors by not accurately reconciling hospital discharge medications and not ensuring timely and accurate medication administration. For one resident with a principal diagnosis of surgical aftercare following digestive system surgery, the facility did not properly transcribe a hospital discharge order for doxycycline, an antibiotic prescribed for a surgical wound infection. Instead, the order was incorrectly entered as pyridoxine (Vitamin B6), resulting in the resident missing six doses of the prescribed antibiotic. This error was identified after the resident was rehospitalized for wound dehiscence and infection, with documentation confirming the medication error and the delay in appropriate treatment. Another resident with a diagnosis of hypertension experienced a medication error when two different LPNs administered the same morning dose of antihypertensive medications, Lisinopril and Metoprolol, resulting in the resident receiving double the prescribed dosage. The error occurred because the first nurse failed to document the administration in the electronic medication administration record (EMAR) after being called away for an emergency, and the second nurse, seeing no documentation, administered the medications again. The incident was discovered later that morning, and the resident required close monitoring and intravenous fluids as a result of the double dosing. Both incidents were attributed to failures in following facility policy regarding medication reconciliation and administration, including accurate transcription of orders, timely documentation in the EMAR, and ensuring the five rights of medication administration. The deficiencies directly affected two of four sampled residents, resulting in missed antibiotic therapy and duplicate antihypertensive dosing, with one resident requiring rehospitalization for wound complications.
Some of the Latest Corrective Actions taken by Facilities in Mississippi
- Implemented facility-wide staff in-services on Elopement/Unsafe Wandering, Missing-Resident emergency procedures, and Abuse/Neglect protocols to reinforce preventive practices (J - F0689 - MS)
- Established ongoing person-centered in-services whenever new residents are identified as elopement risks to ensure individualized preventive strategies are understood by staff (J - F0689 - MS)
- Updated the Medication Administration Record to require hourly visual monitoring of at-risk residents for continuous oversight (J - F0689 - MS)
- Added hourly visual-check tasks in Point of Care for CNAs with mandatory documentation to verify consistent implementation of supervision measures (J - F0689 - MS)
Failure to Develop and Implement Care Plan for Sexually Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing sexually inappropriate behaviors for a resident with a known history of such behaviors. Despite documented incidents of sexually inappropriate comments and actions, including a prior event where the resident asked to see a staff member's breasts and a psychiatric evaluation noting sexually impulsive behavior, the care plan was not updated to include individualized interventions, monitoring instructions, or staff guidance. The resident's cognitive status was severely impaired, as indicated by a Brief Interview for Mental Status score of 6 and psychiatric notes describing poor judgment, impaired decision-making, and confusion. On the day of the incident, the resident inappropriately touched the breasts of two female residents in the day room. After the first incident was witnessed by a staff member, the resident was taken to his room but left unsupervised. Another staff member, unaware of the incident, assisted the resident back to the day room, where a second incident occurred. Both female residents involved had severe cognitive impairment and required staff assessment for mental status. The facility had prior knowledge of the resident's sexually inappropriate behaviors but did not implement immediate supervision or restrictions to protect other residents. Interviews with facility staff confirmed that the care plan was not updated until after the incidents occurred, despite escalating behaviors and psychiatric recommendations. The lack of timely and effective care planning and supervision resulted in two residents experiencing non-consensual sexual contact and placed other vulnerable residents at risk.
Removal Plan
- Hold QA meeting to review Abuse Policy and Care plan policies with all disciplines.
- Start 1-1 observation by DON and ADON when an incident is reported, assigned to the scheduled Certified Nursing Assistant (CNA).
- Conduct in-services on Abuse, Identifying Sexual Abuse, and Capacity to Consent by Staff Development Nurse and Administrator. Train all staff that if staff witnesses abuse, the perpetrator or initiator cannot remain in contact with other residents and must be taken to a supervisor or another employee must remain with them until a decision is made. Do not allow staff to work until in-serviced.
- Discipline and educate LPN on 1-1 supervision when there is an abuse allegation.
- Educate CNA on proper undergarment placement for Resident.
- Update Care Plans for all Residents involved and review all residents with behaviors and their care plans.
- Conduct body audits on Residents.
- Initiate hourly checks on Residents.
- Send referrals to multiple Geri-psych units and other facilities for Resident.
- Assign 1-1 observation of Resident to the scheduled Certified Nursing Assistant (CNA) and use Post Event Hourly Monitoring Form.
- Review Care Plans on Residents with behaviors weekly for 4 weeks, monthly for 3 months, and then quarterly. Social Services Director and Care Plan Nurse will be responsible for reviewing and addressing in QA.
Failure to Protect Residents from Sexual Abuse Due to Lack of Supervision and Communication
Penalty
Summary
The facility failed to protect residents from sexual abuse by not implementing immediate supervision or restrictions for a male resident with a known history of sexually inappropriate behaviors. Despite prior incidents of sexual comments and inappropriate conduct toward staff, no care plan interventions or increased supervision were put in place before the resident inappropriately touched two female residents in the day room. The first incident occurred when the male resident touched the breast of a female resident, which was witnessed by a janitor who separated the residents and notified an LPN. After the initial incident, the LPN escorted the male resident to his room but left him unsupervised while reporting the event to the DON. During this time, another CNA, unaware of the incident, assisted the male resident back to the day room, where he subsequently inappropriately touched the breast of a second female resident. Staff interviews confirmed that there was a lack of communication regarding the initial incident, and the male resident was not placed on one-to-one supervision until after the second incident occurred. The male resident involved had a history of cognitive impairment, poor judgment, and previous sexually inappropriate verbal behaviors, as documented in his medical and psychiatric records. Both female residents who were touched also had severe cognitive impairments. The facility's failure to implement protective supervision and communicate the risk to all staff resulted in two residents experiencing non-consensual sexual contact and placed other vulnerable residents at risk.
Removal Plan
- Hold QA meeting to review Abuse Policy and Care plan policies with all disciplines.
- Start 1-1 observation by DON and ADON when an incident is reported. Assign this to the scheduled Certified Nursing Assistant (CNA).
- Conduct in-services on Abuse and Identifying Sexual Abuse and Capacity to Consent by Staff Development Nurse and the Administrator. Train all staff that if staff witnesses abuse, the one who perpetrates or initiates abusive behavior cannot remain in contact with other residents. Take them with you to a supervisor or another employee must remain with them until a decision is made as to what needs to be done. Do not allow staff to work until in-serviced.
- Discipline and educate LPN #1 on 1-1 supervision when there is an abuse allegation.
- Educate CNA #1 on proper undergarment placement for Resident #2.
- Update Care Plans for all Residents involved and review all residents with behaviors and their care plans.
- Conduct body audits on Resident #2 and Resident #3.
- Initiate hourly checks on Resident #2 and Resident #3.
- Send referrals to multiple Geri-psych units and other facilities for Resident #1.
- Assign 1-1 observation of Resident #1 to the scheduled Certified Nursing Assistant (CNA). Use Post Event Hourly Monitoring Form.
- Review Care Plans on Residents with behaviors weekly for 4 weeks, monthly for 3 months, and then quarterly. Social Services Director and Care Plan Nurse will be responsible for reviewing and addressing in QA.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of depression, repeated falls, and chronic atrial fibrillation was able to exit the facility unsupervised. The resident was last seen by staff at 10:37 AM and subsequently left the building behind a hospice nurse, with no staff intervening to prevent the exit. The resident was observed by a physical therapist assistant (PTA) leaving the facility, but the PTA assumed the resident was accompanied by staff and did not verify this or intervene. The resident continued out of the facility and was not stopped or redirected by any staff members, despite facility policies requiring supervision and intervention for residents at risk of elopement. The resident was outside and unsupervised for approximately 22 minutes, during which time she traveled 0.4 miles away from the facility, down a busy four-lane street, and was eventually found in the parking lot of a local funeral home. The resident was dressed in a sweatshirt and jeans, and the temperature was 51 degrees Fahrenheit. Interviews with staff revealed that there was a lack of immediate response to the resident's absence, and the missing resident procedure was not initiated promptly. Staff failed to maintain awareness of the resident's movements near the exit, and the facility's wandering and missing resident procedures were not followed as required. The facility's policy required that residents at risk for elopement be identified, have preventative plans of care implemented, and receive visual supervision as necessary. In this incident, the resident was not identified as being at risk for elopement at the time, and staff did not provide the required supervision or intervention. The failure to follow established procedures and to provide adequate supervision resulted in the resident being placed in a situation likely to cause serious injury, harm, impairment, or death.
Removal Plan
- Initiated a search within the building and outside the parameters for Resident #9 upon notification of elopement.
- Administrator checked Resident #9's room and the front entrance.
- Social Service Director (SSD) and Physical Therapy Assistant (PTA) assisted in searching outside.
- Located Resident #9 in front of the funeral home, 0.4 miles from the facility.
- Ensured Resident #9 was safe and uninjured.
- SSD called Resident #9's Resident Representative (RR) and informed her of the incident.
- Printed census for North and South unit and completed a head count to ensure all residents were accounted for.
- Completed a body audit on Resident #9 by RN with no injuries noted.
- Reported the incident to the State Agency.
- Maintenance completed an audit on all doors and windows to ensure proper functioning.
- On-call Nurse Practitioner (NP) notified and new order for in-house psych evaluation given.
- Medical Director, Medical Doctor (MD), and NP #2 notified by Administrator of the incident.
- All staff in-services began on Elopement/Unsafe wandering plan and the Emergency Procedure - Missing Resident and Abuse and Neglect; completed by Assistant Director of Nursing (ADON).
- Conducted an Elopement Drill by Maintenance Director, completed on all shifts and to be continued weekly for four weeks and monthly for three months.
- Held an emergency Quality Assurance Performance Improvement (QAPI) meeting with IDT members to discuss the incident, actions to be taken, and further interventions.
- Reviewed policy with QAPI committee; no recommendations for change.
- Added Resident #9 to the wander book and provided a wander guard.
- Person-centered in-services to be completed with staff whenever any new residents are identified as an elopement risk.
- Elopement drill on all shifts and one elopement drill per week on alternating shifts for four weeks, then monthly for three months.
- Head count by census.
- Maintenance quality check on all doors and windows.
- SSD to complete 100% audits on all wanderers, update wander book, update care plans, in-service on wander book location, conduct interview with resident for any psychosocial harm.
- Updated Medication Administration Record (MAR) with hourly visual monitoring for Nursing by RN.
- Point of Care (POC) updated for hourly visual tasks for CNAs to mark complete by MDS Nurse.
- SSD conducted interview with resident to assess psychosocial harm.
- Placed Wander Guard bracelet on Resident #9's left wrist.
- Care plans updated by SSD.
- 100% audit done on all wanderers by SSD and Wander Book updated with photos and face sheets.
- 100% audit done by SSD on all Wander Guard bracelets to ensure appropriate functional ability.
- Maintenance Director to perform elopement drills on all shifts, continue for four weeks and monthly for three months, and bring results before the QAPI committee each month for review and recommendations.
- Any issues to be addressed immediately by the Administrator and the DON.
- Incident reported to the Attorney General's Office by Administrator.
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