FORT WORTH, TX - Federal inspectors cited a local nursing facility for critical safety failures after a resident with dementia escaped through his bedroom window and another resident sustained a head injury when he fell from an unsecured wheelchair during transport.
Critical Wound Care System Breakdown
Inspectors identified immediate jeopardy conditions at Estates Healthcare and Rehabilitation Center on February 14, 2025, following the discovery of severe wound care failures affecting Resident #1. The facility's treatment systems failed at multiple levels, creating serious risks for vulnerable residents requiring specialized wound management.
The inspection revealed that Resident #1 had not received prescribed wound vacuum therapy treatments as ordered by physicians. Wound vacuum therapy, also known as negative pressure wound therapy, represents a critical treatment modality for serious pressure injuries and surgical wounds. These devices work by applying controlled negative pressure to wounds through specialized dressing systems, promoting healing by removing excess fluid, reducing bacterial load, and encouraging new tissue formation.
When the resident specifically requested wound vacuum dressing changes, nursing staff reportedly delayed the treatment rather than addressing it immediately. The facility's investigation uncovered that essential wound care supplies were not readily accessible to nursing staff, forcing delays in treatment delivery. Treatment nurses reported difficulty locating necessary materials, and the wound vacuum equipment was not properly maintained or monitored for functionality issues such as loss of suction, dressing leakage, or kinked tubing.
Medical protocols require wound vacuum therapy dressings to be changed according to precise schedules established by treating physicians, typically every 48-72 hours depending on wound characteristics and drainage volume. Failure to maintain these treatment schedules can result in serious complications. When negative pressure therapy is interrupted or delayed, wound healing progression stalls, bacterial colonization increases, and tissue breakdown may accelerate. For patients with compromised healing capacity due to diabetes, vascular disease, or malnutrition, these delays can transform manageable wounds into life-threatening conditions.
The inspection documented that Resident #1 had not received comprehensive head-to-toe skin assessments according to facility protocols. Such assessments serve as the foundation for identifying early-stage pressure injuries, monitoring existing wounds, and adjusting treatment plans. Without systematic evaluation, wounds can deteriorate undetected, progressing from superficial tissue damage to deep injuries affecting muscle and bone.
Pressure injuries develop when sustained pressure on skin and underlying tissues restricts blood flow, depriving cells of oxygen and nutrients. Stage 3 and 4 pressure ulcers—which extend into deep tissue layers—create substantial risks including severe pain, systemic infection, sepsis, and mortality. The failure to prevent these injuries or provide appropriate treatment represents a fundamental breakdown in basic nursing care standards.
Resident Escapes Through Bedroom Window
On February 3, 2025, Resident #99—a 92-year-old man with dementia who resided in the facility's secure memory care unit—pried open his bedroom window and escaped from the facility at approximately 5:30 AM. Staff discovered him missing approximately 15 minutes later when a nurse entered his room to administer morning medications.
The resident managed to remove window security screws, raise the window, push out the screen, and climb through the opening despite being in his 90s. He then crossed the facility's secured courtyard—where staff later found his bedside table next to the privacy fence—and traveled 0.9 miles from the facility on foot. Two nurses eventually located Resident #99 crossing the street in front of a gas station nearly a mile away.
When staff approached the resident, he became combative and was found carrying a dinner knife, fork, and shaving razor. He used these items as weapons, swinging at one nurse and causing scratches to her arms and face. Staff eventually persuaded him to enter a vehicle and return to the facility, where he was placed on one-to-one supervision before being transferred to a hospital emergency room for psychiatric evaluation.
The escape exposed multiple security system failures in the facility's memory care unit. While the unit's entrance/exit doors were equipped with alarms and keypad locks, individual resident room windows had no monitoring systems. Staff relied solely on physical barriers—screws limiting how far windows could open—without backup monitoring to detect tampering or removal of these security devices.
Elopement from memory care facilities creates severe safety risks for residents with cognitive impairment. Individuals with dementia often lack awareness of environmental dangers, may not recognize traffic hazards, and can become disoriented quickly once outside familiar surroundings. Weather exposure, dehydration, injury from falls, and becoming victims of crime represent documented risks. Additionally, residents who elope may miss scheduled medications for chronic conditions including heart disease, diabetes, and hypertension, potentially triggering acute medical crises.
The inspection revealed that Resident #99's care plan identified him as being at risk for wandering and elopement, noting that he wandered one to three days per week. His care plan specified interventions including close supervision, regular compliance rounds when he was in his room, and instructions to stay with the resident and notify the charge nurse if he exhibited exit-seeking behavior. However, these interventions proved insufficient to prevent the escape.
Staff interviews revealed inconsistent understanding of monitoring responsibilities. While nurses and certified nursing assistants stated they conducted rounds every two hours in the secure unit, this frequency proved inadequate for a resident with documented elopement risk who was reportedly awake and mobile during early morning hours. The resident had weapons and dining utensils in his possession, indicating that security protocols for potentially dangerous items were also not effectively implemented.
Transportation Safety Failure Results in Head Injury
On February 6, 2025, Resident #67 experienced a serious injury when he fell backward in his wheelchair inside the facility's transport van. The incident occurred during takeoff in the facility's parking lot, suggesting the resident was not properly secured before the vehicle began moving.
The fall caused the resident to strike his head on the van floor, resulting in injuries that required emergency hospital evaluation and treatment. Medical records documented that Resident #67 was treated for head injury and a contusion of the right hand. Head injuries in elderly residents carry substantial risks including intracranial bleeding, skull fractures, and traumatic brain injury. Even seemingly minor head trauma can produce serious complications in older adults, particularly those taking anticoagulant medications or with pre-existing conditions affecting bleeding risk.
Federal regulations and industry standards require specific protocols for transporting residents in wheelchairs. Wheelchairs must be positioned in designated securement areas with wheelchair-specific tie-down systems that anchor the frame at four points. Separate occupant restraint systems—typically a lap belt and shoulder harness—must secure the resident's body independently from the wheelchair. These dual-system requirements exist because wheelchairs themselves are not designed to withstand crash forces, and residents need protection separate from their mobility devices.
The inspection findings indicated the facility failed to ensure proper implementation of these safety protocols. Either the wheelchair was not adequately secured to the vehicle floor, the resident was not properly restrained with occupant restraints, or both failures occurred simultaneously. The incident demonstrated that facility staff either lacked proper training in wheelchair securement procedures or failed to follow established protocols.
Additional Issues Identified
Beyond the immediate jeopardy violations, inspectors documented several other compliance concerns. The facility's quality assurance systems failed to detect the wound care deficiencies before they reached crisis levels. Documentation systems did not ensure that treatment orders were consistently followed or that supplies needed for specialized treatments remained accessible.
The facility's elopement prevention systems relied too heavily on single-point security measures without adequate redundancy. Memory care units typically implement multiple overlapping security layers including door alarms, motion sensors, video monitoring, and increased staffing ratios for residents with elopement risk. The facility's approach focused primarily on door security while leaving windows vulnerable despite housing residents with documented exit-seeking behaviors.
Staff training records revealed that while orientation included elopement prevention education, ongoing competency verification and scenario-based drills occurred inconsistently. Following Resident #99's escape, the facility conducted emergency training sessions with all staff, but these reactive measures highlighted the absence of proactive, regular training that might have prevented the incident.
Following identification of the immediate jeopardy conditions, facility administrators implemented corrective measures including comprehensive skin assessments for all residents, verification of wound care supply availability, staff education on wound vacuum therapy procedures, enhanced window security checks in the memory care unit, and daily testing of door alarm systems. Nursing leadership received intensive training on notification procedures for changes in resident condition and proper wound care protocols.
The facility also revised monitoring procedures to ensure wound care supplies remained readily accessible, implemented daily administrative rounds to verify security system functionality in the memory care unit, and established monthly rotation of keypad access codes to prevent unauthorized entry or exit from secured areas.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Estates Healthcare and Rehabilitation Center from 2025-02-14 including all violations, facility responses, and corrective action plans.
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