**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to protect the resident's right to be free from neglect by not ensuring one (#1) out of seven residents with a known history of exit seeking behaviors, and an expressed desire to leave the facility, was provided supervision and services to prevent elopement. The facility failed to properly secure an exit gate, or implement proper methods to prevent elopement, on 10/9/2023 and 10/15/2023. The facility nursing staff neglected to ensure the safety of Resident # 1. Resident # 1 was able to exit the facility unsupervised on 10/9/2023 and 10/15/2023. On 10/9/2023, Resident # 1 self-propelled out a fire exit door leading to a smoking patio and exited the facility unwitnessed through a gate leading into a parking lot next to a busy highway. On 10/15/2023 Resident # 1 exited the facility unwitnessed through the same fire door leading on to a smoking patio, where he gained access to an unattended key attached to the fence, unlocked the gate, and exited from the facility. Staff found him outside the facility heading down the street, next to the busy highway with a high volume of traffic. Resident #1 had been assessed as at risk for elopement, was care-planned to have a wander device on, and had an active order for 1:1 supervision. This neglect created a situation that resulted in the likelihood for serious injury and/or death to Resident # 1 and resulted in the determination of Immediate Jeopardy on 10/9/2023. The findings of Immediate Jeopardy were determined to be removed on 10/27/2023 and the severity and scope was reduced to a D after verification of removal of Immediate Jeopardy Finding Included: Review of Resident Information Record dated 10/26/2023 showed Resident # 1 was originally admitted to the facility on [DATE], with diagnosis that include Muscle Weakness (Generalized), Unsteadiness on Feet, Adjustment Disorder with Mixed Disturbance of Emotions and Conduct, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Review of the admission Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate impairment. Review of the current physician orders dated 10/07/2023, showed Resident #1 had an active order dated 10/09/2023 for an Electronic Monitoring Device on his right ankle to be monitored every shift (Q Shift); Check the functionality on the Electronic Monitoring Device per manufacturer instructions alarm notification every shift (q night shift), or blinking light every shift, to alert exit seeking attempts. Further review showed Resident # 1 had an active order dated 10/12/2023 for one-on-one care for safety, uncontrolled exit seeking until Friday (no date specified). Review of an Elopement Risk Form dated 10/08/2023 showed Resident # 1 scored a 13 revealing he was at risk for elopement. Further review showed the resident wandered, but never eloped, and expressed desires to leave. Additional review of the Elopement Risk assessment dated of 10/09/2023, showed the resident scored a 12 revealing he was at risk for elopement, was alert and oriented, knows who he is and where he is, but not what time it is or what is happening to him, wanders, but had never eloped, independent with wheelchair, and was actively exit - seeking. The summary and decision guide revealed an Electronic Monitoring Device was applied on the resident right ankle. Review of a progress note marked late entry dated 10/09/2023 by Staff C, Registered Nurse (RN) Assistant Director of Nursing (ADON) showed at 8:14am Resident was very angry during rounds and potential to violent due to his threatening behaviors. At 9:33am Noted not in the unit. Ground search identified not in the facility. Code Elopement announced. Exited in the back door inside the location and wheeled back. Elopement risk -assessed. Medical Director was notified. Wife unreachable message left. Electronic monitoring device ordered in the [electronic medical record] -placed in the right ankle #7277 exp. 082024. Review of a progress note dated 10/10/2023 by the Nursing Home Administrator (NHA) showed This writer/Director of Nurses (DON) met with resident. He appears more calm this am, however, is still about his wife. He wants to go see her at the hospital. This writer agreed to follow up on possibility of a hospital visit, otherwise will arrange a Video Call. Resident more coherent today and able to verbalize family support with two children, however, perseverates on wife's status/location and desires to be with her. Review of a progress note dated 10/14/2023 by Staff J, Registered Nurse (RN) Risk Manager showed, This writer was approached by the resident voicing concerns stated that he felt like a prisoner and wanted device removed from his ankle, this writer tried to educate on safety. Electronic monitoring device was removed from the resident ankle and placed on his wheelchair. Resident no longer agitated and yelling out. Further review of the electronic medical record showed no documentation related to Resident # 1 exiting the facility on 10/15/2023. Review of the resident's care plan dated 10/08/2023 with a revision date of 10/25/2023 showed resident was an elopement risk, wanders related to confusion and seeking his wife with interventions that included provide redirection as appropriate, initiated 10/8/2023 with a revision date of 10/25/2023; Provide frequent checks of whereabouts as necessary, initiated 10/8/2023 with a revision date of 10/25/2023. Further review showed a behavior care plan dated 10/10/2023 with a revision date of 10/25/2023, related to hitting and being verbally abusive related to wanting to leave the facility and seeking his wife with interventions that included Increased monitoring and supervision of resident and or visitors of resident, initiated 10/10/2023. Review of Psychiatric Note dated 10/10/2023, showed Resident # 1 was diagnosed with adjustment disorder with anxiety, unspecified dementia, unspecified severity, with mood disturbance. Resident denied any pain but was very concerned about his wife, who had apparently fallen and broke her hip and was having surgery at the hospital. Resident appeared agitated and angry during interview and reported that if he does not find his wife he will start killing people. Further review of the psychiatric visit summary showed, The [skilled nursing facility] has patient on 1:1 for now to help with his aggression and behaviors. An interview was conducted with Staff A, Registered Nurse (RN) on 10/25/23 at 3:10 p.m. She remembered that Resident # 1 was very angry, and he wanted to be with his wife. Staff A stated, I am not sure what the situation was. I think there was a plan for her to be here, but I don't know what happened. Resident # 1 knew where his wife was, but he didn't want to be here. He compared his stay here to being in jail and he made attempts to leave. He was put on 1-1 supervision. He would sit by the exit and try to get out when staff or people would go out the doors. On 10/9/23 I don't remember an elopement being called that day, but Resident # 1 was on 1-1 supervision the whole time he was here up until he was discharged from the facility. I believe Resident # 1 got out before my shift started on 11-7, but I wasn't here. When I got to work on that day there was no education, or anything being talked about regarding Resident # 1 eloping. I wasn't his nurse that day. An interview was conducted with Staff B, Registered Nurse (RN) on 10/25/23 at 3:23 p.m. She stated I remember Resident # 1 briefly; his room was in the red hall. He was on 1-1 supervision and always had someone with him. He was exiting seeking, and I'm not sure of his cognition. I think he voiced a wanting to leave the facility. I worked on 10/9/2023 and I don't remember there being an elopement called on 10/9/23. An interview was conducted with Staff C, Registered Nurse (RN), Assistant Director of Nursing (ADON) on 10/25/23 at 3:40 p.m. She said Resident # 1 was not one on one supervision when he was admitted ; he was placed on one on one after the situation happened on 10/9/2023. At the time. I think we already put him on a wanderguard on him because he kept saying he was going to go out and go to his wife. She said she came to work between the hours of 7 or 8 a.m., and the situation with Resident # 1 happened between 9 and 10. Staff C stated, I did not think the situation was an elopement because to my understanding Resident # 1 was seen by somebody inside our facility, that is not an elopement. I did not write he was not in the facility; I mean not in the building. I didn't know the resident was under supervision on that day. We just knew he wasn't in his room. We announced an elopement, but I don't remember the time and I cannot remember any more. I don't know who said Resident # 1 wasn't in his room and I don't know who found the resident. When they found him, he had no injuries and no signs of bleeding. No skin assessment was completed. Resident # 1 said he was just trying to look for somebody to help him when he left the facility. He went out the door without us knowing he had left. His wife fell and was hospitalized . He was an elopement risk on elopement precautions, wander device placed in the right ankle. Staff C said the elopement risk on 10/10/2023 was not complete. She said she started the assessment because the resident had got out the day before. Staff C stated, One of the supervisors did the assessment and I was just checking it to go over it. She said When I reviewed the resident's orders, I had not discontinued the one-to-one order. I was not notified it was ever discontinued. It was still active when he left. An interview was conducted with Staff C, Registered Nurse (RN) ADON at 10/25/23 4:39. She said on 10/9/23 a therapy staff member saw the resident in the backyard. Staff C stated We were having a meeting on 10/9/23 when one of the therapists came to the door and told everyone in the meeting that a patient was not found in the unit. Everyone left the meeting and started looking for the resident. I went to the front door to see if the resident was located there but he was not there, then me and the DON [director of nursing] did an elopement drill. The DON told me they found the patient in the back yard next to the gazebo. I did not go out to the parking lot but there were people cutting the grass at the time, and I presumed the gate was open because they were cutting the grass. An interview was conducted with Staff D, Dietary [NAME] on 10/25/23 at 4:30 p.m. He said Resident # 1 was in a wheelchair when he saw him at first, he did not know who the resident was, but he knew that he had to be a resident at the facility when he saw a bandage on his face. He said he saw the resident outside of the gate in parking lot on left side of building when he got to work. He stated I didn't have my cell phone. So, I went into the building to get someone. Two CNAs came to help the resident, everyone that worked that day had to do an in-service and sign a paper. I talked to the DON and gave a verbal statement. I did not get asked for a written statement. An interview was conducted with Staff E, a Physical Therapy Assistant (PTA) on 10/26/23 at 10:14 a.m. Staff E said on 10/9/2023 Monday morning between 9-9:30 a.m. I pulled off highway 52 into the parking lot and parked in the 6th parking spot from the road. I saw a gentleman in a wheelchair in the middle of the parking lot. No one was with him at that time. He was moving in his wheelchair, dressed in regular clothes. I pulled into the first spot and went to talk to him. He kept moving and was behind my car. He was very agitated. I noticed his incision and thought he must be a resident. I grabbed my phone to call someone inside the facility to come out to assist me with the resident. Resident # 1 was going backwards at this point towards the road. I called my boss right away and told her [Staff G] I had a resident outside that was agitated and I needed help. Everyone came running out to help assist with getting the resident back inside the facility. He was strong and by that time we were probably a few parking spaces closer to the road. They were able to get him back in the building. I left at that point because the Nursing Home Administrator said she didn't need me. An interview was conducted with Staff F, Certified Nursing Assistant (CNA), on 10/26/2023 at 9:43 a.m. She said, I worked with Resident # 1 several times. I was one to one with the resident on 10/14/2023 until 11:30 p.m. On 10/15/2023 I was assigned to the resident as his aide but not as one on one supervision. I told the nurse I was taking a 15 min break, and I went out to my car. I saw a CNA running and the guy said someone just left. The resident was up by the highway on the sidewalk rolling in his wheelchair. I, the CNA, and the manager on duty went after the resident to bring him back to the facility. The manager on duty went to get more staff to assist us because we couldn't control the resident. He was so combative with us he tried to get up and fell out of his wheelchair. We had to pick him up and help him back into his wheelchair. There were no alarms going off when we got back to the facility because the door the resident got out, leading to the smoking courtyard, had no alarm system on it. It took us about 45 minutes or up to an hour to get the resident back inside the facility because the resident was resisting. He got out from the same smoking area he exited before. They put him under 1-1 supervision when he got here and then they took him off. I think it was on his ankle, but he kept messing with it, so they put it on the electronic monitoring device on his chair. After the second time he got out, he was put back on one to one. He was very confused and just wanted to go see his wife. An interview was conducted with Staff G, Registered Nurse/Resident Care Coordinator, MDS, (RN) on 10/26/23 at 10:39 a.m. Staff G confirmed she was the manager on duty on 10/15/2023 and said, On 10/15/23 I was going out to courtyard because a resident was out there, and he waved me out because he wanted a soda. I was manager on duty that day. When I went out there a resident said a gentleman had just gone out of the gate. I went out the gate and closed it behind me. I didn't see him towards the back of the building. I turned left and saw him in the direction toward the road. A dietary person was out there, and a CNA came out to help. When I got to him, he was on the sidewalk next to highway 52. We were telling him to come back, and he was trying to get away. He grabbed hold of a silver rail along the sidewalk so we couldn't move him. We were running, but he was quicker. We told him he needed to come back, and it wasn't safe for him to be outside. He kicked me in the shin and tried to hit the CNA. He grabbed the rail when we were trying to move him, pulled himself up and he fell out of the chair. He reopened a skin tear on his arm. Once there were a few more people out there, I ran back to get his nurse and she came out to assess him. He really liked his nurse, and she was able to get him back inside the building. He let us help him get back in wheelchair. There was a key hanging off to the side of the gate lock. He unlocked the lock and got out of the gate. The DON came in that day and double checked to make sure residents and staff were ok. The DON came to me this morning to do elopement training. She asked me what to do when a resident tries to elopement, how to call one. An interview was conducted with Staff H, the Director of Rehabilitation on 10/26/23 at 12:01 p.m. She said On Monday morning, I got a phone call from [Staff E] when I was in the morning meeting. Between 9:30 and 10:00. Staff E told me when she pulled into the parking lot, she saw a patient outside. She called me to tell me she was with the resident and needed assistance. I just told everyone in the meeting. We immediately began searching. He was outside by the old therapy gym on the left side of the building. An interview was conducted with the Director of Nursing (DON) on 10/26/23 at 11:04 p.m. The DON stated, On 10/9/23 we were having a morning meeting. [Staff H] got a phone call from [Staff E], telling her a resident was outside of the facility gate. We looked out the window and saw the lawn people were outside too and the gate was open. We all got up and went outside. [Staff E] was with him the whole time outside in the parking lot. From my understanding the gate was opened by lawn maintenance people. Our gate has a key for emergencies. The lawn people had the gate open, and the resident got out of the gate. [Staff E] said she was coming into work and saw the resident in the parking lot. When I went out and saw him, he just kept saying 'I want my wife, I want my wife.' Education didn't start specifically that day; we started education the following week during our town hall meeting. We have an Advance Registered Nurse Practitioner (ARNP) for psychiatry and Psychologist. Both saw him on 10/11/23. I think we increased activities, and increased entertainment. The resident was redirectable. I did not consider either event on 10/9/2023 and 10/15/2023 to be an elopement because the staff was with the resident. Prior to him getting out he was not 1-1. We increased activity around that hallway. We were putting extra staff down there to encourage extra eyes. I think they put 1-1 on the staffing sheet to monitor him more closely. An interview was conducted with Staff I, Registered Nurse, (RN). Resident Care Coordinator on 10/26/23 at 10:30 a.m. I worked on 10/9/23 but not 10/15/23. I was here and tried to help get Resident # 1 in the facility. I was in a morning meeting, and someone said there was a resident in the parking lot with a therapist. I went out of the meeting to help assist with bringing him back inside the facility, but he was difficult and agitated. He wanted to see his wife. It took three of us to get him back inside the facility. We tried to redirect him and calm him down and turned his wheelchair to back him in. We got him back in. A wander guard was placed on 10/9/23 and the Wanderguard was added to his care plan. I didn't update the resident care plan after he got out on 10/15/23. An interview was conducted with Staff J, the Registered Nurse (RN) Risk Manager (RM) on 10/26/23 at 2:20 p.m. The Director of Rehab came in the building and said Resident # 1 was outside with her therapist. We went outside and brought him back in. At that point, he got out of the side gate from the smoking patio. It was a day the landscapers were here. The gate was still open. We put him on one on one and he had a wanderguard. There is no wanderguard system alarm on the door he went out and the door to go to the smoking patio from the building is open all the time. Somehow the resident wasn't one to one if he got out. I told the CNA she could help on the floor in that area. There were aides on the floor, so I felt like someone was always going to be there. On Sunday morning I didn't tell staff to take the resident off one to one. There was an aide just sitting there not doing anything so I said she could help. I have no idea why the resident wasn't one to one that Sunday. The RM confirmed if a 1:1 was assigned it would be on the daily staffing sheet but confirmed a 1:1 was not listed. The RM stated I was not part of the investigation they conducted regarding the resident getting out; the NHA conducted the investigation. We did not consider the resident eloped because he was seen going outside the gate. As a risk manager I would usually deal with elopements, but I am still in training or whatever. An interview was conducted with the Nursing Home Administrator (NHA) on 10/26/23 at 2:45 p.m. On 10/9/23 we were having a morning meeting, and the rehab director received a telephone call that one of her staff members was outside with Resident # 1. We left the morning meeting and went to assist in getting the resident back inside the building. I think DON and I discussed what happened, and we had identified the landscapers were here and he had gone through the courtyard gate the first time. Staff E was the one that observed him at the gate. Continuing, the NHA said, I would have to look at her statement and see what she told us. I thought we had a statement from her, but I don't see it here. I think we did get a statement. The NHA said We were able to redirect him and bring him back to the building. He was reassessed and the interdisciplinary team made recommendations for interventions. I don't know what the interventions were. The NHA continued On 10/15/23 it was reported to me Resident # 1 had exited out the courtyard gate. He opened the lock with the key that was attached to the gate. A dietary staff member was in his car and observed him unlock the lock and exit out the gate. He saw a CNA and asked her to help assist the resident. Staff G went out and a CNA was with the resident. I was told there were multiple staff involved because the resident became combative. It was not reported to me he was off the property, and I do not know of a timeline when the resident would have got out the gate. I was told he sustained a fall and had an abrasion on his arm. Afterward the DON and I communicated. She was here and we talked about completing house wide elopement assessments. We talked about staff education. The next day we had an Adhoc QAPI meeting with the team to discuss how this happened and what we can do to prevent it. I know we increased the level of supervision on the red hall where the resident had resided. I don't know if we maintained one to one supervision 24-7. We did not consider it an elopement because he did not exit the courtyard; He did not leave the premises. The NHA continued, I don't know if there was a timeline done to see the last time staff would have seen Resident # 1. We conducted our investigation together as a team. I don't remember a timeline being done. The NHA confirmed the definition of elopement would be 'A patient who left the premises of the facility without permission or off the property' but stated I think it depends on the circumstances with the patient, and the patient's condition. No, this it is not an elopement to me. The NHA confirmed documentation related to both incidents was incomplete in the clinical record. An interview was conducted with the Medical Director on 10/26/23 at 10:58 a.m., I was made aware the resident left the facility. I would have to look at text messages. I was made aware twice. We reviewed his medicines, and I don't think we gave him any more sedatives. He just wanted to speak to his wife. She was in the hospital as well. I don't think it was an elopement. I don't know what the definition of elopement was. I was told he was seen by the staff leaving his room. I was told he was in the courtyard I believe. Elopement is to my knowledge is when staff are not aware of his where abouts. I was made aware of him trying to leave and the nurses and another person were with him. On 10/9/2023 the temperature was 78 degrees Fahrenheit and on 10/15/2023 the temperature was 78 degrees Fahrenheit according to www.weather.com. State Highway 52 is a 6-lane state road with speed limits ranging from 35 miles per hour to 55 miles per hour, according to www.fdot.gov. Observations revealed a sidewalk on one side of the road (the side which the facility was located) and a mild gradient, with 3 lanes of traffic traveling in both directions (six lanes total). Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation [ANEM] of Property Prevention, Protection and Response Policy and Procedures Revised draft date 03/2022, revealed, Policy. Abuse, Neglect, Exploitation and Misappropriation of Property, collectively known and referred to as ANEM and as hereafter defined, will not be tolerated by anyone, including staff, patients, volunteers, family members as legal guardians, friends, or any other individuals. Definitions: Neglect: The failure of the facility, its employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor and/or supervise the delivery or patient care and services to assure that care is provided as needed by the patient. Policy: Patients with needs and behaviors that might lead to conflict with staff or other patients will be identified by the interdisciplinary Care Planning Team, with interventions and follow through designed to minimize the risk of conflict. III. Prevention Issues: Procedures: Any patient identified as having behaviors which might lead to conflict or neglect, such a. Patient with history of aggressive behaviors The interventions designed to meet the needs of such patients will include but will not be limited to: b. Assessment of appropriate intervention strategies to prevent occurrences, c. Monitoring the patient for any changes that would trigger abusive behaviors. d. Reassessment of the protective strategies on a regular basis. Identification Issues: Policy: Any patient event that is reported to any staff by patient, family, other staff, or any other person will be considered as possible ANEM if it meets any of the following criteria: g. Any instances of hitting, slapping, pinching, or kicking or other potentially harmful action. Review of the facility policy titled Wandering and Elopements Revised date March 2019, revealed, Policy Heading The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the resident from leaving in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. 3. If a resident is missing, initiate the elopement/ missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). 4. When the resident returns to the facility, the director of nursing services or charge nurse shall: a. Examine the resident for injuries. b. Contact the attending physician and report the findings and conditions of the resident. c. notify search teams that the resident has been located. d. document relevant information in the resident's medical record. On 10/27/2023 at 3:36 p.m. the Nursing Home Administrator provided a removal plan showing the following facility steps to remove the Immediate Jeopardy: 1. Resident # 1 was discharged on 10/20/2023. On 10/27/2023, immediately upon alleged abuse/ neglect, designee called resident # 1 current location to ensure resident safety. 2. On 10/27/2023 the allegations of neglect were reported to Abuse Registry via online reporting and the AHCA immediate report was completed 3. On 10/16/2023 a root cause analysis was completed with the development of a performance improvement plan 4. On 10/15/2023 elopement risk assessment was completed on 100% of the resident population 5. On 10/27/2023 at 1:45 pm, Risk Manager and 2 MDS RNs began reassessing 100% of current resident population for elopement risk. The care plans for those residents assessed as moderate/high risk were reviewed to ensure appropriate interventions. Education 1. On 16/2023, staff were provided with education regarding Wandering, elopement, and prevention tips: 2. On 10/19/2023, staff education was provided regarding Wandering, elopement, and prevention tips as well as emergency code and expectation related to staff response. 3. On 10/27/2023, Licensed nurses have been educated on transcription of physician orders to include specific start/stop dates of interventions. 4. On 10/27/2023, staff have been educated in routine resident checks. 5. On 10/26/2023, staff were educated on resident/ staff safety and facility security as it relates to the location of the key for the locks on the courtyard. 6. On 10/26/2023, Carefree education was delivered via text and / or email to all staff regarding resident/ staff safety and facility security as it relates to the location of the key for the locks on the courtyards. 7. On 10/26/2023, an auditing tool was implemented for auditing the location of courtyard keys and verification of secured locks on the gate. 8. AN Ad hoc QAPI meeting on 10/27/2023 to discuss all interventions included in the plan of abatement. Facility administrative staff were educated on 10/27/2023 of the Federal definition of elopement and a notification to the Medical Director and the Ombudsman. On 10/27/2023 at 4:00 p.m., An observation showed the keys to both gates have been relocated away from the gate. Photographic evidence was obtained. On 10/27/2023 at 6:00 p.m. the definition of elopement from the Florida Healthcare Association and Center for Medicare and Medicaid Services (CMS), was reviewed and discussed with all facility staff by the Nursing Home Administrator, the Director of Nurses, and the Corporate Regional Nurse. An interview was conducted with the Nursing Home Administrator (NHA), Director of Nursing (DON) and the Corporate Regional Nurse (CRN) on 10/27/23 at 6:01 p.m. The NHA said elopement, the new key location and gate lock education was provided to all staff including the Medical Director. The courtyard gate keys were immediately removed and relocated to another location. The NHA stated We have a performance improvement plan that was put in place related to elopements, resident safety, and assessments/ care plans. The root cause of the elopement was a resident was able to have access to a key that was hanging from the gate located in the smoking courtyard and was able to unlock the gate and get out. We remediated the situation by relocating the key from the gate and we [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide supervision and services to prevent unwitnessed exits from the facility, on two occasions, for one (Resident # 1) of seven residents at high-risk of elopement. This failure created a situation which resulted in the likelihood for serious injury, harm and/or death to Resident # 1, and resulted in the determination of Immediate Jeopardy on 10/09/2023. The findings of Immediate Jeopardy were determined to be removed on 10/27/2023, and the scope and severity was reduced to a D after verification of removal of Immediate Jeopardy. Resident # 1 is a [AGE] year-old male who was moderately cognitively impaired, at risk for falls related to unsteadiness on his feet, was known to staff to have a history of wandering and expressed a desire to leave the facility. On 10/09/2023 Resident # 1 self-propelled out a fire exit door leading to a smoking patio and exited the facility unwitnessed through a gate leading into a parking lot next to a busy highway. On 10/15/2023 Resident # 1 exited the facility unwitnessed through the same fire door leading on to a smoking patio, where he gained access to an unattended key attached to the fence, unlocked the gate, and exited from the facility. Staff found him outside the facility heading down the street, next to the busy highway with a high volume of traffic. Resident #1 had been assessed as at risk for elopement and was care-planned to have a wander device on. Resident # 1 was at risk of straying onto a 6-lane main highway, putting him at risk of being stuck by a vehicle and suffering serious injuries. Findings included: Review of Resident Information Record dated 10/26/2023 showed Resident # 1 was originally admitted to the facility on [DATE], with diagnosis that include Muscle Weakness (Generalized), Unsteadiness on Feet, Adjustment Disorder with Mixed Disturbance of Emotions and Conduct, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Review of the admission Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate impairment. Review of the current physician orders dated 10/07/2023, showed Resident #1 had an active order dated 10/09/2023 for an Electronic Monitoring Device on his right ankle to be monitored every shift (Q Shift); Check the functionality on the Electronic Monitoring Device per manufacturer instructions alarm notification every shift (q night shift), or blinking light every shift, to alert exit seeking attempts. Further review showed Resident # 1 had an active order dated 10/12/2023 for one-on-one care for safety, uncontrolled exit seeking until Friday (no specified date). Review of an Elopement Risk Form dated 10/08/2023 showed Resident # 1 scored a 13 revealing he was at risk for elopement. Further review showed the resident wandered, but never eloped, and expressed desires to leave. Additional review of the Elopement Risk assessment dated of 10/09/2023, showed the resident scored a 12 revealing he was at risk for elopement, was alert and oriented, knows who he is and where he is, but not what time it is or what is happening to him, wanders, but had never eloped, independent with wheelchair, and was actively exit - seeking. The summary and decision guide revealed an Electronic Monitoring Device was applied on the resident right ankle. Review of a progress note marked late entry dated 10/09/2023 by Staff C, Registered Nurse (RN) Assistant Director of Nursing (ADON) showed at 08:14 Resident was very angry during rounds and potential to violent due to his threatening behaviors. At 09:33 Noted not in the unit. Ground search identified not in the facility. Code Elopement announced. Exited in the back door inside the location and wheeled back. Elopement risk -assessed. Medical Director was notified. Wife unreachable message left. Electronic monitoring device ordered in the [electronic medical record] -placed in the right ankle #7277 exp. 082024. Review of a progress note dated 10/10/2023 by the Nursing Home Administrator (NHA) showed This writer/Director of Nurses (DON) met with resident. He appears more calm this am, however, is still about his wife. He wants to go see her at the hospital. This writer agreed to follow up on possibility of a hospital visit, otherwise will arrange a Video Call. Resident more coherent today and able to verbalize family support with two children, however, perseverates on wife's status/location and desires to be with her. Review of a progress note dated 10/14/2023 by Staff J, Registered Nurse (RN) Risk Manager showed, This writer was approached by the resident voicing concerns stated that he felt like a prisoner and wanted device removed from his ankle, this writer tried to educate on safety. Electronic monitoring device was removed from the resident ankle and placed on his wheelchair. Resident no longer agitated and yelling out. Further review of the electronic medical record showed no documentation related to Resident # 1 exiting the facility on 10/15/2023. Review of the resident's care plan dated 10/08/2023 with a revision date of 10/25/2023 showed resident was an elopement risk, wanders related to confusion and seeking his wife with interventions that included provide redirection as appropriate, initiated 10/8/2023 with a revision date of 10/25/2023; Provide frequent checks of whereabouts as necessary, initiated 10/8/2023 with a revision date of 10/25/2023. Further review showed a behavior care plan dated 10/10/2023 with a revision date of 10/25/2023, related to hitting and being verbally abusive related to wanting to leave the facility and seeking his wife with interventions that included Increased monitoring and supervision of resident and or visitors of resident, initiated 10/10/2023. Review of Psychiatric Note dated 10/10/2023, showed Resident # 1 was diagnosed with adjustment disorder with anxiety, unspecified dementia, unspecified severity, with mood disturbance. Resident denied any pain but was very concerned about his wife, who had apparently fallen and was at the hospital. Resident appeared agitated and angry during interview and reported that if he does not find his wife he will start killing people. Further review of the psychiatric visit summary showed, The [skilled nursing facility] has patient on 1:1 for now to help with his aggression and behaviors. An interview was conducted with Staff A, Registered Nurse (RN) on 10/25/23 at 3:10 p.m. She remembered that Resident # 1 was very angry, and he wanted to be with his wife. Staff A stated, I am not sure what the situation was. I think there was a plan for her to be here, but I don't know what happened. Resident # 1 knew where his wife was, but he didn't want to be here. He compared his stay here to being in jail and he made attempts to leave. He was put on 1-1 supervision. He would sit by the exit and try to get out when staff or people would go out the doors. On 10/9/23 I don't remember an elopement being called that day, but Resident # 1 was on 1-1 supervision the whole time he was here up until he was discharged from the facility. I believe Resident # 1 got out before my shift started on 11-7, but I wasn't here. When I got to work on that day there was no education, or anything being talked about regarding Resident # 1 eloping. I wasn't his nurse that day. An interview was conducted with Staff B, Registered Nurse (RN) on 10/25/23 at 3:23 p.m. She stated I remember Resident # 1 briefly; his room was in the red hall. He was on 1-1 supervision and always had someone with him. He was exiting seeking, and I'm not sure of his cognition. I think he voiced a wanting to leave the facility. I worked on 10/9/2023 and I don't remember there being an elopement called on 10/9/23. An interview was conducted with Staff C, Registered Nurse (RN), Assistant Director of Nursing (ADON) on 10/25/23 at 3:40 p.m. She said Resident # 1 was not one on one supervision when he was admitted ; he was placed on one on one after the situation happened on 10/9/2023. At the time. I think we already put him on a wanderguard on him because he kept saying he was going to go out and go to his wife. She said she came to work between the hours of 7 or 8 a.m., and the situation with Resident # 1 happened between 9 and 10. Staff C stated, I did not think the situation was an elopement because to my understanding Resident # 1 was seen by somebody inside our facility, that is not an elopement. I did not write he was not in the facility; I mean not in the building. I didn't know the resident was under supervision on that day. We just knew he wasn't in his room. We announced an elopement, but I don't remember the time and I cannot remember any more. I don't know who said Resident # 1 wasn't in his room and I don't know who found the resident. When they found him, he had no injuries and no signs of bleeding. No skin assessment was completed. Resident # 1 said he was just trying to look for somebody to help him when he left the facility. He went out the door without us knowing he had left. His wife fell and was hospitalized . He was an elopement risk on elopement precautions, wander device placed in the right ankle. Staff C said the elopement risk on 10/10/2023 was not complete. She said she started the assessment because the resident had got out the day before. Staff C stated, One of the supervisors did the assessment and I was just checking it to go over it. She said When I reviewed the resident's orders, I had not discontinued the one-to-one order. I was not notified it was ever discontinued. It was still active when he left. An interview was conducted with Staff C, Registered Nurse (RN) ADON at 10/25/23 4:39. She said on 10/9/23 a therapy staff member saw the resident in the backyard. Staff C stated We were having a meeting on 10/9/23 when one of the therapists came to the door and told everyone in the meeting that a patient was not found in the unit. Everyone left the meeting and started looking for the resident. I went to the front door to see if the resident was located there but he was not there, then me and the DON [director of nursing] did an elopement drill. The DON told me they found the patient in the back yard next to the gazebo. I did not go out to the parking lot but there were people cutting the grass at the time, and I presumed the gate was open because they were cutting the grass. An interview was conducted with Staff D, Dietary [NAME] on 10/25/23 at 4:30 p.m. He said Resident # 1 was in a wheelchair when he saw him at first, he did not know who the resident was, but he knew that he had to be a resident at the facility when he saw a bandage on his face. He said he saw the resident outside of the gate in parking lot on left side of building when he got to work. He stated I didn't have my cell phone. So, I went into the building to get someone. Two CNAs came to help the resident, everyone that worked that day had to do an in-service and sign a paper. I talked to the DON and gave a verbal statement. I did not get asked for a written statement. An interview was conducted with Staff E, a Physical Therapy Assistant (PTA) on 10/26/23 at 10:14 a.m. Staff E said on 10/9/2023 Monday morning between 9-9:30 a.m. I pulled off highway 52 into the parking lot and parked in the 6th parking spot from the road. I saw a gentleman in a wheelchair in the middle of the parking lot. No one was with him at that time. He was moving in his wheelchair, dressed in regular clothes. I pulled into the first spot and went to talk to him. He kept moving and was behind my car. He was very agitated. I noticed his incision and thought he must be a resident. I grabbed my phone to call someone inside the facility to come out to assist me with the resident. Resident # 1 was going backwards at this point towards the road. I called my boss right away and told her [Staff G] I had a resident outside that was agitated and I needed help. Everyone came running out to help assist with getting the resident back inside the facility. He was strong and by that time we were probably a few parking spaces closer to the road. They were able to get him back in the building. I left at that point because the Nursing Home Administrator said she didn't need me. An interview was conducted with Staff F, Certified Nursing Assistant (CNA), on 10/26/2023 at 9:43 a.m. She said, I worked with Resident # 1 several times. I was one to one with the resident on 10/14/2023 until 11:30 p.m. On 10/15/2023 I was assigned to the resident as his aide but not as one on one supervision. I told the nurse I was taking a 15 min break, and I went out to my car. I saw a CNA running and the guy said someone just left. The resident was up by the highway on the sidewalk rolling in his wheelchair. I, the CNA, and the manager on duty went after the resident to bring him back to the facility. The manager on duty went to get more staff to assist us because we couldn't control the resident. He was so combative with us he tried to get up and fell out of his wheelchair. We had to pick him up and help him back into his wheelchair. There were no alarms going off when we got back to the facility because the door the resident got out, leading to the smoking courtyard, had no alarm system on it. It took us about 45 minutes or up to an hour to get the resident back inside the facility because the resident was resisting. He got out from the same smoking area he exited before. They put him under 1-1 supervision when he got here and then they took him off. I think it was on his ankle, but he kept messing with it, so they put it on the electronic monitoring device on his chair. After the second time he got out, he was put back on one to one. He was very confused and just wanted to go see his wife. An interview was conducted with Staff G, Registered Nurse/Resident Care Coordinator, MDS, (RN) on 10/26/23 at 10:39 a.m. Staff G confirmed she was the manager on duty on 10/15/2023 and said, On 10/15/23 I was going out to courtyard because a resident was out there, and he waved me out because he wanted a soda. I was manager on duty that day. When I went out there a resident said a gentleman had just gone out of the gate. I went out the gate and closed it behind me. I didn't see him towards the back of the building. I turned left and saw him in the direction toward the road. A dietary person was out there, and a CNA came out to help. When I got to him, he was on the sidewalk next to highway 52. We were telling him to come back, and he was trying to get away. He grabbed hold of a silver rail along the sidewalk so we couldn't move him. We were running, but he was quicker. We told him he needed to come back, and it wasn't safe for him to be outside. He kicked me in the shin and tried to hit the CNA. He grabbed the rail when we were trying to move him, pulled himself up and he fell out of the chair. He reopened a skin tear on his arm. Once there were a few more people out there, I ran back to get his nurse and she came out to assess him. He really liked his nurse, and she was able to get him back inside the building. He let us help him get back in wheelchair. There was a key hanging off to the side of the gate lock. He unlocked the lock and got out of the gate. The DON came in that day and double checked to make sure resident and staff were ok. The DON came to me this morning to do elopement training. She asked me what to do when a resident tries to elopement, how to call one. An interview was conducted with Staff H, the Director of Rehabilitation on 10/26/23 at 12:01 p.m. She said On Monday morning, I got a phone call from [Staff E] when I was in the morning meeting. Between 9:30 and 10:00. Staff E told me when she pulled into the parking lot, she saw a patient outside. She called me to tell me she was with the resident and needed assistance. I just told everyone in meeting. We immediately began searching. He was outside by the old therapy gym on the left side of the building. An interview was conducted with the Director of Nursing (DON) on 10/26/23 at 11:04 p.m. The DON stated, On 10/9/23 we were having a morning meeting. [Staff H] got a phone call from [Staff E], telling her a resident was outside of the facility gate. We looked out the window and saw the lawn people were outside too and the gate was open. We all got up and went outside. [Staff E] was with him the whole time outside in the parking lot. From my understanding the gate was opened by lawn maintenance people. Our gate has a key for emergencies. The lawn people had the gate open, and the resident got out of the gate. [Staff E] said she was coming into work and saw the resident in the parking lot. When I went out and saw him, he just kept saying 'I want my wife, I want my wife.' Education didn't start specifically that day; we started education the following week during our town hall meeting. We have an Advance Registered Nurse Practitioner (ARNP) for psychiatry and Psychologist. Both saw him on 10/11/23. I think we increased activities, and increased entertainment. The resident was redirectable. I did not consider either event on 10/9/2023 and 10/15/2023 to be an elopement because the staff was with the resident. Prior to him getting out he was not 1-1. We increased activity around that hallway. We were putting extra staff down there to encourage extra eyes. I think they put 1-1 on the staffing sheet to monitor him more closely. An interview was conducted with Staff I, Registered Nurse, (RN). Resident Care Coordinator on 10/26/23 at 10:30 a.m. I worked on 10/9/23 but not 10/15/23. I was here and tried to help get Resident # 1 in the facility. I was in a morning meeting, and someone said there was a resident in the parking lot with a therapist. I went out of the meeting to help assist with bringing him back inside the facility, but he was difficult and agitated. He wanted to see his wife. It took three of us to get him back inside the facility. We tried to redirect him and calm him down and turned his wheelchair to back him in. We got him back in. A wander guard was placed on 10/9/23 and the Wanderguard was added to his care plan. I didn't update the resident care plan after he got out on 10/15/23. An interview was conducted with Staff J, the Registered Nurse (RN) Risk Manager (RM) on 10/26/23 at 2:20 p.m. The Director of Rehab came in the building and said Resident # 1 was outside with her therapist. We went outside and brought him back in. At that point, he got out of the side gate from the smoking patio. It was a day the landscapers were here. The gate was still open. We put him on one on one and he had a wanderguard. There is no wanderguard system alarm on the door he went out and the door to go to the smoking patio from the building is open all the time. Somehow the resident wasn't one to one if he got out. I told the CNA she could help on the floor in that area. There were aides on the floor, so I felt like someone was always going to be there. On Sunday morning I didn't tell staff to take the resident off one to one. There was an aide just sitting there not doing anything so I said she could help. I have no idea why the resident wasn't one to one that Sunday. The RM confirmed if a 1:1 was assigned it would be on the daily staffing sheet but confirmed a 1:1 was not listed. The RM stated I was not part of the investigation they conducted regarding the resident getting out; the NHA conducted the investigation. We did not consider the resident eloped because he was seen going outside the gate. As a risk manager I would usually deal with elopements, but I am still in training or whatever. An interview was conducted with the Nursing Home Administrator (NHA) on 10/26/23 at 2:45 p.m. On 10/9/23 we were having a morning meeting, and the rehab director received a telephone call that one of her staff members was outside with Resident # 1. We left the morning meeting and went to assist in getting the resident back inside the building. I think DON and I discussed what happened, and we had identified the landscapers were here and he had gone through the courtyard gate the first time. Staff E was the one that observed him at the gate. Continuing, the NHA said, I would have to look at her statement and see what she told us. I thought we had a statement from her, but I don't see it here. I think we did get a statement. The NHA said We were able to redirect him and bring him back to the building. He was reassessed and the interdisciplinary team made recommendations for interventions. I don't know what the interventions were. The NHA continued On 10/15/23 it was reported to me Resident # 1 had exited out the courtyard gate. He opened the lock with the key that was attached to the gate. A dietary staff member was in his car and observed him unlock the lock and exit out the gate. He saw a CNA and asked her to help assist the resident. Staff G went out and a CNA was with the resident. I was told there were multiple staff involved because the resident became combative. It was not reported to me he was off the property, and I do not know of a timeline when the resident would have got out the gate. I was told he sustained a fall and had an abrasion on his arm. Afterward the DON and I communicated. She was here and we talked about completing house wide elopement assessments. We talked about staff education. The next day we had an AdHoc QAPI meeting with the team to discuss how this happened and what we can do to prevent it. I know we increased the level of supervision on the red hall where the resident had resided. I don't know if we maintained one to one supervision 24-7. We did not consider it an elopement because he did not exit the courtyard; He did not leave the premises. The NHA continued, I don't know if there was a timeline done to see the last time staff would have seen Resident # 1. We conducted our investigation together as a team. I don't remember a timeline being done. The NHA confirmed the definition of elopement would be 'A patient who left the premises of the facility without permission or off the property' but stated I think it depends on the circumstances with the patient, and the patient's condition. No, this it is not an elopement to me. The NHA confirmed documentation related to both incidents was incomplete in the clinical record. An interview was conducted with the Medical Director on 10/26/23 at 10:58 a.m., I was made aware the resident left the facility. I would have to look at text messages. I was made aware twice. We reviewed his medicines, and I don't think we gave him any more sedatives. He just wanted to speak to his wife. She was in the hospital as well. I don't think it was an elopement. I don't know what the definition of elopement was. I was told he was seen by the staff leaving his room. I was told he was in the courtyard I believe. Elopement is to my knowledge is when staff are not aware of his where abouts. I was made aware of him trying to leave and the nurses and another person were with him. On 10/9/2023 the temperature was 78 degrees Fahrenheit and on 10/15/2023 the temperature was 78 degrees Fahrenheit according to www.weather.com. State Highway 52 is a 6-lane state road with speed limits ranging from 35 miles per hour to 55 miles per hour, according to www.fdot.gov. Observations revealed a sidewalk on one side of the road (the side which the facility was located) and a mild gradient, with 3 lanes of traffic traveling in both directions (six lanes total). Review of the facility policy titled Wandering and Elopements Revised date March 2019, revealed, Policy Heading The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the resident from leaving in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. 3. If a resident is missing, initiate the elopement/ missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). 4. When the resident returns to the facility, the director of nursing services or charge nurse shall: a. Examine the resident for injuries. b. Contact the attending physician and report the findings and conditions of the resident. c. notify search teams that the resident has been located. d. document relevant information in the resident's medical record. On 10/27/2023 at 3:36 p.m. the Nursing Home Administrator provided a removal plan showing the following facility steps to remove the Immediate Jeopardy: 1. Resident # 1 was discharged on 10/20/2023. On 10/27/2023, immediately upon alleged abuse/ neglect, designee called resident # 1 current location to ensure resident safety. 2. On 10/27/2023 the allegations of neglect were reported to Abuse Registry via online reporting and the AHCA immediate report was completed 3. On 10/16/2023 a root cause analysis was completed with the development of a performance improvement plan 4. On 10/15/2023 elopement risk assessment was completed on 100% of the resident population 5. On 10/27/2023 at 1:45 pm, Risk Manager and 2 MDS RNs began reassessing 100% of current resident population for elopement risk. The care plans for those residents assessed as moderate/high risk were reviewed to ensure appropriate interventions. Education 1. On 16/2023, staff were provided with education regarding Wandering, elopement, and prevention tips: 2. On 10/19/2023, staff education was provided regarding Wandering, elopement, and prevention tips as well as emergency code and expectation related to staff response. 3. On 10/27/2023, Licensed nurses have been educated on transcription of physician orders to include specific start/stop dates of interventions. 4. On 10/27/2023, staff have been educated in routine resident checks. 5. On 10/26/2023, staff were educated on resident/ staff safety and facility security as it relates to the location of the key for the locks on the courtyard. 6. On 10/26/2023, Carefree education was delivered via text and / or email to all staff regarding resident/ staff safety and facility security as it relates to the location of the key for the locks on the courtyards. 7. On 10/26/2023, an auditing tool was implemented for auditing the location of courtyard keys and verification of secured locks on the gate. 8. AN Ad hoc QAPI meeting on 10/27/2023 to discuss all interventions included in the plan of abatement. Facility administrative staff were educated on 10/27/2023 of the Federal definition of elopement and a notification to the Medical Director and the Ombudsman. On 10/27/2023 at 4:00 p.m., An observation showed the keys to both gates have been relocated away from the gate. Photographic evidence was obtained. On 10/27/2023 at 6:00 p.m. the definition of elopement from the Florida Healthcare Association and Center for Medicare and Medicaid Services (CMS), was reviewed and discussed with all facility staff by the Nursing Home Administrator, the Director of Nurses, and the Corporate Regional Nurse. An interview was conducted with the Nursing Home Administrator (NHA), Director of Nursing (DON) and the Corporate Regional Nurse (CRN) on 10/27/23 at 6:01 p.m. The NHA said elopement, the new key location and gate lock education was provided to all staff including the Medical Director. The courtyard gate keys were immediately removed and relocated to another location. The NHA stated We have a performance improvement plan that was put in place related to elopements, resident safety, and assessments/ care plans. The root cause of the elopement was a resident was able to have access to a key that was hanging from the gate located in the smoking courtyard and was able to unlock the gate and get out. We remediated the situation by relocating the key from the gate and we ordered breakaway key boxes on 10/26/23. The boxes were shipped on 10/26/2023 and will be delivered on Tuesday of next week. We had an AdHoc QAPI meeting and started our Performance Improvement Plan (PIP), focusing on location of the keys and the security of the gate. The Elopement assessments for residents were reviewed at 100% today with no discrepancies found. I filed an immediate report, report #190839. We sent out an automated in-service system to make sure that all staff were provided with education regarding elopement and the new changes with the keys and resident safety. We crossed referenced to ensure everyone was reached the system sends via text and email. We will also in-service staff as they come in starting yesterday. All staff are being educated before returning to work in person. Elopement education was completed at the town hall, held on 10/19/2023 were we discussed elopement codes and what to do if an elopement happens. The DON said the facility conduct townhall meetings with clinical staff monthly. On 10/27/2023 starting at 5:00p.m., interviews were conducted with 34 staff members, which included 8 licensed nurses, 12 CNAs and 14 non licensed staff. Attempts were made to contact 15 additional staff who were off duty. All staff members were able to state that they had been trained and were knowledgeable about the new policies. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 10/27/2023 and the non-compliance was reduced to a scope and severity of D.