**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide routine supervision and monitoring for one of 93 residents (Resident 1) and failed to implement interventions developed to help prevent an elopement (unauthorized and unsupervised exit from the facility) when: 1) On August 1, 2023, staff was unaware Resident 1 (a confused resident with cognitive deficit and required assistance with walking) had eloped from the facility. In addition, it was not identified Resident 1 was missing from the facility despite Resident 1 not being present during the evening meal (Resident 1 required direct 1:1 [one to one] staff assistance during mealtime). This failure resulted in Resident 1 subsequently being found (by non-facility staff) in a neighboring backyard unresponsive, on the ground, and covered with vomit. Resident 1 required hospitalization and intubation (a tube placed through the airway to help the resident breath when they are unable to breath on their own). This also had the potential to result in death to Resident 1 due to exposure of the (outdoor) elements and without vital resources such as food, water, and shelter. 2) The facility ' s front door alarm was not armed to audibly alert staff (as specified in the facility ' s policy and procedure for elopement prevention) and staff did not provide supervision of the facility ' s main entrance and exit while the alarm was unarmed. This failure resulted in staff to not be alerted to the unauthorized exit of Resident 1 from the facility and therefore, did not provide staff an opportunity to prevent the Resident 1 ' s elopement by responding to the area in a timely manner to divert Resident 1 back into the facility. Findings: 1) A review of Resident 1 ' s clinical record titled, admission Record (contains medical and demographic information) dated August 2, 2023, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included Craniotomy (surgical opening in the skull), altered mental status, unsteady gait (walking uncoordinated), Epilepsy (Neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions), anxiety disorder (feelings of fear and/or worry that interfere with daily activities), and restlessness and agitation. During a review of Resident 1 ' s Minimum Data Set (MDS), Section C - Cognitive Patterns (section used to determine a resident cognitive functioning status) dated, July 31, 2023, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS a score 0-15 used to determine cognitive functioning) score of 3 (severe impairment). During a review of Resident 1 ' s MDS, Section G Functional Status dated, July 31, 2023, the MDS indicated Resident 1 required, .2 (Limited Assistance .staff provide guided maneuvering of limbs or other non-weight-bearing assistance .one person physical assist.). During a review of Resident 1 ' s History and Physical (H&P) dated July 28, 2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s care plan (an individualize plan of care) dated July 28, 2023, the care plan titled, At risk for re-hospitalization r/t [related to] hx [history of] altered mental status, [confusion] HTN [elevated blood pressure], alcohol dependence [When the person can ' t stop drinking alcohol] craniotomy [surgery of the skull]. The interventions included, .Turn and reposition every 2 hours and PRN [as needed] for circulation and comfort. During a review of Resident 1 ' s physician orders, dated July 27, 2023, the order indicated, one to one feeding assistance . During a review of Resident 1 ' s care plan dated July 28, 2023, the care plan titled, The resident has limited physical mobility r/t weakness/unsteadiness of feet . The interventions included, .Provide supportive care, assistance with mobility as needed . During an interview on August 4, 2023, at 12:28 PM, with the Administrator (ADMIN), the ADMIN stated Resident 1 eloped from the facility on August 1, 2023, and was last seen by staff in the facility at 3:15 PM. The ADMIN further stated the facility staff was unaware Resident 1 was missing until around 7:15 PM (four hours later) on August 1, 2023, when Resident 1 ' s family called the facility to notify them Resident 1 was in the hospital. During an interview on August 4, 2023, at 3:23 PM with the Director of Nursing (DON), the DON stated Certified Nurse Assistant 1 (CNA 1) was assigned to care for Resident 1 but failed report to Licensed Vocational Nurse (LVN 1) Resident 1 was not present for, and did not eat his dinner when it was served at 5:00 PM. The DON further stated CNA 1 did not look for Resident 1 to determine the whereabouts of Resident 1. The DON stated the CNA 1 should have checked on Resident 1 more frequently throughout the shift. During an interview on August 7, 2023, at 4:22 PM with CNA 1, CNA 1 stated that she was not aware Resident 1 required 1:1 (one on one) assistance with eating his meals and that CNA 2 delivered Resident 1 ' s meal tray to his room at approximately 5:00 PM on August 1, 2023. CNA 1 further stated she picked up Resident 1 ' s dinner tray at approximately 8:30PM and it was untouched, but she (CNA 1) did not look for Resident 1 and did not assist Resident 1 during dinner mealtime. During an interview on August 8, 2023, at 3:04 PM with CNA 2, CNA 2 stated she delivered Resident 1 ' s dinner tray to his room on August 1, 2023. CNA 2 stated when she delivered the tray, she noticed Resident 1 was not in his room. CNA 2 further stated she asked Resident 1 ' s roommate where Resident 1 was at and the roommate informed her that Resident 1 was in therapy. CNA 2 stated she left the meal tray inside Resident 1 ' s room but never looked for or checked on Resident 1. CNA 2 stated Receptionist 2 (R2) came to Resident 1 ' s room looking for Resident 1, and the tray was still in the room, untouched. CNA 2 stated CNA 1 should have provided Resident 1 assistance with his meal. During a review of the facility ' s job description for Certified Nurse Assistant dated 2003, the job description indicated, The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident ' s assessment and care plan as may be directed by your supervisors ., ensure that residents who are unable to call for help are checked frequently ., check each resident routinely to ensure that his / her personal needs are being met in accordance with his/her wishes ., serve food trays. Assist with feeding as indicated (i.e., cutting, foods, feeding assist in the dining room supervision, etc.) . immediately notify the nurse supervisor/charge nurse of any resident leaving/missing from the facility. During a review of CNA 1 ' s Counseling/Disciplinary Notice dated, August 1, 2023, the document indicated, Failure to do rounds adequately to ensure the safety of your patients. During an interview on August 7, 2023, at 3:06 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated it was her first time working with Resident 1 and she did not see Resident 1 from the beginning of her shift around 3:00 PM, because she got busy with her assignment. LVN 1 further stated, CNA 1 did not report to her that Resident 1 did not eat his dinner. LVN 1 stated she did not check on or look for Resident 1. During a review of the facility ' s job description for Licensed Vocational Nurse dated 2003, the job description indicated, The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by nursing assistants ., make daily rounds of your unit / shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards ., make periodic checks to ensure the prescribed treatment are being properly administered by certified nursing assistants and to evaluate the resident ' s physical and emotional status ., ensure that residents who are unable to call for help are checked frequently . During a review of LVN 1 ' s Counseling / disciplinary notice, dated, August 1, 2023, signed by LVN 1, the document indicated, .Failure to be accountable for your patients to ensure their safety. During an interview on August 7, 2023, at 3:47 PM with Receptionist 2 (R2), R2 stated that on August 1, 2023, around 7:15 PM she received a phone call from Resident 1 ' s family member to inform the facility Resident 1 was admitted to the hospital. Resident 1 ' s family wanted to speak to the facility ' s Registered Nurse 1 (RN 1). During an interview on August 7, 2023, at 4:45 PM with RN 1, RN 1 stated on August 1, 2023, around 7:15 PM, Resident 1 ' s family called to inform the facility Resident 1 was missing from the facility and Resident 1 was admitted to the Emergency Department. RN 1 stated she looked around the facility for Resident 1, but she was not able to find him. RN 1 further stated the ADMIN checked the surveillance camera located by the main entrance and noticed Resident 1 walked out of the facility at approximately 3:30 PM. RN 1 stated she knew Resident 1 needed full assistance with meals. RN 1 stated she did not check if Resident 1 received assistance with his meals. During a review of the RN job description dated 2003, the job description indicated, The primary purpose of your job position is to supervise the day-to-day nursing activities of the facility during your tour of duty ., ensure that all nursing service personal are in compliance with their respective job description ., make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standard. Report findings to the Director . During a review of Resident 1 ' s care plan titled, Resident 1 has impaired cognitive function or impaired thought process related to head injury/craniotomy ., dated July 28, 2023, the care plan indicated, .Interventions .Cue, reorient and supervise as needed. During a review of Resident 1 ' s care plan titled, Resident 1 is at risk for falls related to poor safety awareness. dated July 28, 2023, the care plan indicated, .Interventions .The resident needs a safe environment. During a review of Resident 1 ' s care plan titled, Resident 1 has risk for re-hospitalization related to history of altered mental status, HTN, Alcohol dependence, craniotomy . dated July 28, 2023, the care plan indicated, .interventions .Diet as ordered and assist with meals as needed. During a review of Resident 1 ' s medical records from the hospital, dated, August 1, 2023, at 6:08 PM, the records indicated, [AGE] year-old male who presents with a GCS [Glasgow Coma Scale used to describe the extent of impaired consciousness] of 3 [the lowest possible score, unresponsive] after he was found outside someone ' s yard. Patient also noted to be hypotensive [low blood pressure] and have emesis [vomit] on his clothes. He was intubated in the Emergency Department. 2. During an interview on August 4, 2023, at 12:28 PM with the Administrator (ADMIN), the ADMIN stated Resident 1 eloped from the facility on August 1, 2023, and was last seen by staff in the facility at 3:15 PM. The ADMIN further stated Resident 1 eloped from the facility after the main entrance door alarm was disarmed by the receptionist 1 (R1). A review of Resident 1 ' s clinical record title, Interdisciplinary (IDT - team composed of staff from various disciplines) dated August 2, 2023, at 4:50 PM, indicated, per charge nurses, (pt) patient was seen last approx. [approximately] August 1, 2023, at 3:15 PM. Resident was seen in walking from his room to the hallway without helmet. Resident was redirected and encourage to wear his helmet for safety. Resident went back to the room and put on his helmet patient [Pt] has a medical history and not limited to altered mental status, unsteadiness of feet, seizure, HTN (elevated blood pressure) alcohol dependence, (is the body ' s inability to stop drinking) Craniotomy (Surgery into the skull) ., RN supervisor received a call from the hospital, stating that resident was found at someone ' s backyard unresponsive and was brought to [the admitting hospital] for further evaluation ., recommendations: ., all exit door alarm must be functional ., front door alarm will remain armed at all times ., if at any time, the alarm goes off, receptionist / designee needs to be reset alarm immediately to remain functional. During an interview on August 7, 2023, at 2:30 PM, with the ADMIN, the ADMIN stated the facility had a protocol which indicated the door alarm was to be kept ON at all times to prevent elopement of their residents. The ADMIN further stated it was an error from the staff to disarm the main entrance door alarm. During an interview on August 8, 2023, at 8:53 AM with R1 via telephone, R1 stated on August 1, 2023, at 3:00 PM, she disarmed the main entrance alarm because she was working by herself, and it was hard for her to answer the phone calls. R1 stated it was hard to be in two places at the same time, and when Resident 1 eloped from the facility she was probably busy doing something because she missed it. She further stated she was aware that main entrance alarm should be ON at all times to alert the staff if someone was leaving through the front door. During a review of the facility ' s policy and procedure (P&P) titled, Elopement and Wandering Resident ' s dated, December 19, 2022, the P&P indicated, 1. The facility is equipped with door locks / alarms to help avoid elopements., 2. Alarm are not replacement for necessary supervision, Staff are to be vigilant in responding to alarms in a timely manner .d. Adequate supervision will be provided to help prevent accidents or elopements . During a review of the facility ' s P&P titled, Accidents and Supervision dated, December 19, 2022, the P&P indicated, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard and risk (s) ., 3. Implementing interventions to reduce hazard (s) and (risk) ., 4. Monitoring for effectiveness and modifying interventions when necessary ., 5. Supervision-Supervision is an intervention and means of mitigating accident risk. The Facility will provide adequate supervision to prevent accidents. Adequacy of supervision: A. Defined by type and frequency ., B. based on the individual resident ' s assessed needs and identified hazards in the resident environment. An Immediate Jeopardy (IJ-a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents) on August 8, 2023 at 2:16 PM, after determined Resident 1 did not receive supervision and monitoring required to keep Resident 1 safe on August 1, 2023 when Resident 1 was found to have eloped from the facility. The IJ was called in the presence of the Director or Nursing (DON) and Administrator (ADMIN). A Corrective Action Plan (CAP- a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested and a preliminary CAP was received on August 10, 2023, at 2:52 PM and included the following: · Facility staff activated the entrance alarm as soon as she finished answering the phones on August 1, 2023, at approximately 3:30 PM. · Facility Head Count was completed on August 1, 2023, with a total count of 93 in-house residents. Facility head count will continue to be performed on a daily basis. · The DON, and designee(s) re-evaluated 93 residents for risk for wandering/elopement using an elopement risk assessment tool on August 2, 2023. The residents (5) identified on elopement risk continue the use of wander guard. As of August 2, 2023, four of the five residents as who are at elopement risk continue with use of wander guard system, while the other one resident previously identified at risk for elopement is on every two-hour monitoring, due to non-compliance with wearing the wander guard bracelet. Effective August 10, 2023, at 12:00 PM, all elopement risk residents will be monitored every hour on a daily basis. This monitoring will be ongoing at this time. · Nursing will continue to monitor. · Facility staff assigned to resident on August 1, 2023, received an In-service education as it relates to monitoring/supervising of assigned resident by the DON/Administrator. · On August 3, 2023, the facility administrator provided an in-service education to the receptionist related to the facility alarm. · The facility licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel received education on wandering, elopement, wander guard use, and resident safety as per facility policy and procedure, on August 1, 2023, August 2, 2023, and August 3, 2023, from the DON and designee. Any staff on leave will receive education on their next scheduled workday. Facility will continue to perform on going in-service trainings regarding wandering, elopement, resident safety, wander guard use, and resident monitoring/supervision to facility staff monthly for 3 months. · Receptionist desk was re-located next to the entry door to increase supervision and monitor alarm on August 2, 2023. A keyed security box was placed over the alarm keypad to ensure that the alarm can ' t be turned off on August 2, 2023. Everyone must use the bypass keypad to disarm alarm for 45 supervised seconds. The receptionist/administrative team were given an in-service education training regarding these changes on August 2, 2023, and August 3, 2023. · Elopement and wandering resident ' s policy was reviewed on August 2, 2023. · Residents identified at risk for elopement were reviewed by the DON/Designee for appropriate care plan interventions on August 2, 202. If wander guard is implemented, they were checked for appropriate placement, function, and documentation. An in-service education training was provided to facility staff on August 1, 2023, August 2,2023, and August 3, 2023. · On August 3, 2023, an IDT meeting was conducted for residents at risk for elopement to discuss the identified residents at risk for elopement, with documentation in the identified medical record. · An ongoing daily check of facility doors and alarms are performed by the Maintenance Department to ensure function and securement. An increase in the frequency of facility door and alarm checks was initiated on August 2, 2023. · Elopement risk binders were reviewed by the DON/Designee on August 2, 2023, and were up to date. Elopement risk binders are available at each nursing station and at the reception area. Elopement binders are updated by the DSD Monthly and PRN with oversite by the DON. · On August 2, 2023, the administrator reviewed the elopement binder and residents at risk for elopement with the receptionist. · Elopement code drills were initiated on all shifts starting on August 2, 2023, and will continue to perform drills monthly for three months then quarterly thereafter. · New hires will receive education on wandering, elopement, and resident safety by the Director of staff development (DSD). · All In-service education training will continue to be performed with lesson plans. · A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained. The acceptable corrective action was verified with the facility to be implemented through observation, interview, and record review. The IJ was lifted on August 11, 2023, at 3:40 PM, in the presence of the ADMIN and DON.