OAKDALE, LA - A Louisiana nursing home received an immediate jeopardy citation after federal inspectors determined the facility failed to properly respond to two elopement incidents involving the same resident, while also documenting infection control failures during a complaint investigation completed in August 2024.
Resident Exited Facility Unsupervised on Two Occasions
Allen Oaks Nursing and Rehab Center in Oakdale, Louisiana, faced its most serious citation after a resident identified as Resident #R7 exited the facility through the X Hall front door without staff supervision on two separate occasions - June 25, 2024, and August 3, 2024.
According to the inspection report, the facility's Director of Nursing confirmed both incidents occurred but stated the facility did not complete an incident report after the first occurrence on June 25. When asked about investigating the elopement incidents, the DON stated "there was no incident to investigate."
The facility's own policy titled "Elopements" dated December 2007 requires staff to "promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing." A separate policy on "Accidents and Incidents-Investigating and Reporting" mandates that all incidents occurring on premises be investigated and reported to the Administrator.
Despite these documented policies, the DON revealed during an interview on August 16, 2024, that the facility had not implemented any additional interventions to Resident #R7's care plan following either elopement incident. No new staff in-services related to elopement prevention were conducted, and the DON stated he "did not consider these incidents an elopement because Resident #R7 did not leave the facility grounds."
Why Elopement Response Matters
Elopement - when a resident leaves a facility without authorization or appropriate supervision - represents one of the most dangerous safety events in long-term care. Residents who elope face significant risks including exposure to weather extremes, traffic hazards, falls, and inability to access medications or medical care.
Federal regulations require nursing facilities to ensure residents receive adequate supervision and assistive devices to prevent accidents. When an elopement occurs, proper protocol requires immediate investigation, documentation through incident reports, care plan updates with enhanced interventions, and staff education to prevent recurrence.
The failure to document incidents means the facility cannot systematically track patterns, identify root causes, or implement evidence-based prevention strategies. Care plan updates following safety events are essential for communicating revised monitoring approaches across all shifts and staff members.
During the August 16 interview, the Administrator acknowledged awareness of both elopement incidents and confirmed the facility did not complete incident reports or staff training "because the facility did not feel the incidents were elopements." The Administrator also confirmed the care plan was not updated with additional interventions but acknowledged "should have."
The DON further revealed the facility lacked policies related to training staff on elopement risk identification, how to respond after an elopement occurs, or specific procedures for elopement and wandering assessments.
Infection Control Violations Documented
Inspectors also cited Allen Oaks for infection prevention and control failures involving a cognitively impaired resident. Video camera footage from the resident's room, reviewed by investigators, documented multiple infection control lapses by a certified nursing assistant.
On July 19, 2024, footage showed a CNA providing perineal care while standing on a mattress placed on the floor beside the resident's bed. The CNA removed a soiled disposable incontinence brief and placed it directly on the floor mattress rather than in a designated disposal container.
Additional footage from July 23, 2024, at 7:52 p.m. showed the same CNA standing on the floor mattress in areas that appeared wet. The CNA then climbed onto the resident's bed, stood on the mattress to reposition the resident, and walked across the mattress to exit the bed.
Later that evening at 11:02 p.m., footage captured two CNAs providing perineal care with improper technique - cleansing from buttocks toward the labia rather than front to back as required by the facility's perineal care policy dated February 2018. A soiled brief was tossed onto the floor.
Proper Care Standards
The facility's own policy states perineal care purposes include preventing infections and skin irritations, with specific instructions to "wash perineal area, wiping from front to back" and to "discard disposable items into designated containers."
For female residents, proper perineal care technique requires cleansing from front to back to prevent fecal bacteria from entering the urinary tract, which can cause urinary tract infections. UTIs in elderly nursing home residents can lead to serious complications including sepsis, hospitalization, and cognitive changes that may be mistaken for dementia progression.
Standing on resident mattresses creates cross-contamination risks and violates basic infection control principles. When the Administrator reviewed footage of the CNA standing on the resident's bed on July 29, 2024, she confirmed "S3 CNA should have never stood on Resident #1's bed."
During a phone interview, the CNA acknowledged the improper technique, stating she "would have had to move the mattress next to Resident #1's bed and lower the bed but she was in a rush."
Additional Issues Identified
The cited resident receiving improper perineal care was documented as having severe cognitive impairment with a BIMS score of 00. Her diagnoses included altered mental status, dementia, muscle weakness, and difficulty walking. Her care plan noted the presence of a family-provided camera in the room, and she required staff assistance ranging from moderate to total dependence for activities of daily living including toileting hygiene.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Allen Oaks Nursing and Rehab Center from 2024-08-19 including all violations, facility responses, and corrective action plans.
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