**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a vulnerable and severe cognitively impaired resident from exiting the facility unsupervised, and failed to provide adequate supervision and a secure environment for 1 of 3 residents reviewed for elopement, out of a total sample of 29 residents, (#70). On 7/07/23 at approximately 7:05 PM, the facility failed to prevent a vulnerable, cognitively impaired resident with known behaviors of wandering and at high risk for elopement from exiting the facility unsupervised through the unalarmed dining room doors. The facility was unaware of resident #70's whereabouts for 2 hours until a Certified Nursing Assistant (CNA), who was on break, noticed the resident in the rear parking lot. The facility failed to ensure the dining room door alarms were functional, and failed to ensure the resident was adequately supervised to prevent her from exiting the facility. Resident #70 covered a total distance of approximately 300 feet in her wheelchair outside the facility. She could have fallen, sustained injuries from sharp debris, become lost or been hit by a car. The heat index at the time resident #70 was outside, unsupervised was 89 degrees Fahrenheit, which was categorized as Caution, with fatigue possible if prolonged exposure or physical activity, according to the National Weather Service. These failures contributed to the elopement of resident #70 and placed all residents who wandered at risk for serious injury, impairment, or death and resulted in Immediate Jeopardy starting on 7/07/23. Findings: Review of the medical record revealed resident #70 was originally admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital with diagnoses of dementia, abnormalities of gait and mobility, nondisplaced fracture of lateral malleolus of left tibia, muscle weakness, anemia, and anxiety. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 3/30/21 revealed resident #70 was ambulatory with use of assistive device, required one-person assistance for transfers and was at risk for falls. The document indicated the resident was alert, disoriented but could follow simple instructions. The admission Minimum Data Set (MDS) with Assessment Reference Date of 7/05/23 revealed resident #70's Brief Interview for Mental Status was 3 out of 15 indicating she was severely cognitively impaired. The MDS assessment indicated resident #70 required limited assistance with transfers and extensive assistance with walking in her room and in the corridor. Resident #70 required supervision for locomotion. The resident had unsteady balance during transitions and walking and was only able to stabilize herself with staff assistance. She used a wheelchair for mobility and a wander/elopement alarm daily. The Nursing admission Evaluation dated 3/31/21 revealed resident #70 was oriented to person only, confused, had unsteady gait, and used assistive devices for mobility. Review of an Elopement Risk Evaluation dated 4/25/23 revealed resident #70 was a high risk for elopement. The form showed she was ambulatory or self-mobile in wheelchair and was cognitively impaired with poor decision-making skills. The form revealed she had verbally expressed the intent to leave the facility and return home, packed belongings to go home or stayed near an exit door and not accepted redirection. Review of a quarterly Fall Risk Evaluation Tool dated 4/22/23 revealed resident #70 was classified as High Risk for Falls. The form showed resident #70 overestimated or forgot the limits of her ability to ambulate safely. Review of resident #70's care plan for communication related to recent head trauma/injury and language barrier, initiated on 1/04/23, revealed an intervention for staff to anticipate and meet (her) needs. Review of resident #70's care plan for risk for falls related to history of falls/injury, impaired balance, poor coordination, and unsteady gait was initiated on 3/31/21. An intervention directed staff to check routinely and as needed to ensure safety. A care plan initiated on 11/01/21 revealed resident #70 was at risk for periods of anxiety related to dementia and cognitive communication deficit. Interventions directed staff to provide quiet structure and a secure environment. A care plan revised on 9/11/21 revealed resident #70 was at risk for elopement due to her level of dementia and behaviors which included getting into other residents' rooms, and roaming hallways without direction. The goal noted, Resident will not leave facility unattended and whereabouts will be known at all times. Interventions included enhanced supervision as indicated. A progress note dated 4/25/23 revealed the electronic monitoring device system was activated and alerted staff resident #70 was located near an exit door. The note indicated staff assisted resident #70 back to the unit and she was placed on a 15-minute observation. Review of a Situation, Background, Assessment, Recommendations, (SBAR) Communication Form dated 7/07/23 read, Resident was found in the parking lot, head to toe assessment done, no skin concerns, no acute distress noted. Review of an Incident Note dated 7/10/23 revealed Licensed Practical Nurse (LPN) assigned to resident #70 learned she was not in the nursing unit until at approximately 8:52 PM. The note showed resident #70 was found at 9:05 PM behind the cars by a Certified Nursing Assistant (CNA) on her break. On 7/27/23 at 11:29 AM, in a telephone interview, resident #70's son explained on 7/07/23 he received a call from the facility informing him his mother had gotten out. He said he was alarmed as she could have been killed because the facility was located near a major highway. He stated he learned she was out of the building for approximately 20 minutes before anyone noticed it. He shared resident #70 had exhibited exit seeking behaviors but had not left the building before. He noted his mother had dementia and the facility had alarms for her. He indicated the facility neglected her because the door was not secured and they needed to pay close attention to her because she liked to get through the doors or stay near doors. On 7/27/23 at 11:39 AM, in a telephone interview, LPN C explained resident #70 became more confused at sundown. She said she noticed resident #70 looked out for her family in the afternoons, after 7 PM or 8 PM. She recalled the resident liked to open the exit door. LPN C explained the resident did not usually activate the alarm because staff brought her back to her room or the unit before she opened the door. She indicated resident #70 could be found in the memory care room with a staff member. She explained on 7/07/23 she last saw resident #70 before 7 PM sitting quietly in her wheelchair by the hallway. She said she did not see resident #70 again until CNA E asked for her. She recalled she told CNA E the resident was near the memory care room, but when they looked, no one was there. She stated while they searched the unit for resident #70, CNA D called CNA E and told her resident #70 was outside by the rear parking lot. She reported they went out and saw resident #70 with CNA D sitting in her wheelchair. She explained resident #70 was not safe to be outside by herself due to her confusion and dementia. She said she did not know exactly when the resident got out and remembered the resident told her she was looking for her mom. LPN C spoke about the hazards outside and added, Anything could have happened to her. Thank God, we saw her and got her back inside. On 7/27/23 at 12:19 PM, in a telephone interview, CNA D stated resident #70 spent most of her time in the memory care area or by the unit's hallway. She indicated resident #70 was not ambulatory but was able to self-propel in her wheelchair. She recalled resident #70 would say she wanted to go home and sat by the exit doors. She stated she did not see resident #70 opening the door because they always stopped her before she did it. She explained exit-seeking was not a daily behavior and she noticed resident #70 did it when she was not around her friends. CNA D stated the last time she saw resident #70 on 7/07/23 was between 7:00 PM and 7:30 PM in the memory care area with a staff member present. She indicated when it was time for her break, at approximately 8:50 PM, she headed to her car and saw resident #70 outside in the parking lot. She stated she asked resident #70 where she was going but she did not respond. She indicated she called CNA E and told her she found resident #70 outside. She explained she stayed with resident #70 until her assigned nurse and CNA went out to get her because she was not supposed to be out there by herself. She stated she did not know how the resident got out because she was wearing an electronic monitoring device. On 7/27/23 at 2:43 PM, the Maintenance Director stated he was responsible for the safety of the residents, staff, and property. He explained prior to the elopement, all 12 doors were tested twice daily with an electronic monitoring device bracelet, and they were all functional. He recalled he received a call from the Assistant Director of Nursing (ADON) on 7/0/7/23 after 9 PM and she said a resident had eloped. He explained he arrived that night at the facility at approximately 10 PM. He indicated he inspected all exit doors, and no issues were identified. He explained he called their alarm contractor, and the technician visited the facility on Saturday 7/08/23 to check the doors. He stated when the technician came to the facility on Saturday morning, they were not sure which door resident #70 had gone through, and one door was inspected with no issues found. He explained after they reviewed the security camera and learned which door the resident exited from, a second technician came and inspected that door. He stated resident #70 left using door on the north side, which was used for deliveries. He explained only the egress alarm sounded, but it could only be heard by the door and once the door closed, the alarm went off. He explained the interior double doors leading from the unit to the main reception area, doors to the main dining room and to the service hall were not alarmed. He explained the double doors that led to the dining room required a badge to enter but they were wide open the night of the incident. He explained resident #70 pushed on the left side door leading to the back of the building. He recalled during inspection of that door, he noticed the door did not consistently lock when tested with an electronic monitoring device. He said the technician noticed a short circuit preventing the door from functioning properly. He indicated the alarm company had special tools to inspect such equipment, but the facility's daily inspections consisted of pushing doors with the electronic monitoring device to ensure it locked and alarmed as designed. He explained there had been no inspection by the alarm system company since it was installed approximately 3 years ago as the facility had decided not to have routine annual inspection and only call when needed. He acknowledged hazards found outside included an inclined parking lot which led to the kitchen in the old adjacent building. He indicated if resident #70 went down the sloped incline in her wheelchair she could have tilted, sped ahead, fell, or injured herself. He indicated there was a drop to a concrete floor across the one-way road from where the resident exited the building. If she went into the grassy area she could have been stuck and unable to move or go forward. On 7/27/23 at 3:46 PM, CNA E stated they had always had designated staff member, sometimes two, assigned to the memory care room. She indicated resident #70 needed assistance with toileting and she checked on her every 2 hours. She explained when resident #70 was really confused she did not stay in the memory care room. She recalled resident #70 always looked for her mom, stayed near doors and pushed doors but only exit doors were alarmed, so she would activate those if she got near them. CNA E stated she would redirect resident #70 by telling her she would show her where her mom was. She recalled resident #70 did not stay in the memory care room after dinner and would be by the hallway with another resident. She indicated both residents needed to be watched because they had tried to exit when they did not stay in the memory care room, and they liked to self-propel their wheelchairs up and down the hallway. She stated everyone kept an eye on them. She explained at around 7 PM on the night of the incident, the CNA assigned to the memory care room asked her to cover while she went on her break. She could not recall the exact time she saw resident #70 but remembered she was not in the memory care room. She explained there were 4 residents in the memory care room while she was there and 2 of those residents were on her assignment. She said she continued providing care to residents until it was time for her break at approximately 8:30 PM. She repeated she did not pay attention and she did not see the resident before taking her break. She stated she did not ask anyone if they had seen resident #70 even though it was over an hour since she had last seen the resident. She recalled she went out to the porch for her break that overlooked the parking lot. She noted during her 30 minute break, she was the only one on the porch. She explained it was a little bit dark and she did not see resident #70. She indicated when she returned from her break, she asked LPN C if she had seen resident #70 so she could provide care to her. She could not recall the nurse's response, but they began looking for the resident. She reported she received a phone call a few minutes later from CNA D informing her resident #70 was outside. She noted they ran outside and got the resident. She remembered upon returning to the building, the alarm sounded loud, so she did not understand what happened and how the resident got out as she had not heard any alarms before this time. She noted that night she was suspended for 2 weeks and upon her return, she learned resident #70 left the facility through the service hall near the kitchen at about 7:00 PM. She conveyed it was not safe for the resident to be outside by herself as she could have fallen if she had tried to get up, anything could have happened because she was confused. On 7/27/23 at 5:01 PM, Security Staff H stated he was responsible to ensure all doors functioned properly and inspected the inside and outside of the facility daily. He indicated after the daytime receptionist finished her duties between 3 and 4 PM, he covered the front desk. He explained there were times he left the reception desk to fix a television in a resident's room or reset a resident's bed. He indicated when he was on a phone call or checking visitors in, he may not be monitoring the cameras located at the front desk. He stated he inspected the electronic monitoring system on 7/07/23 and there were no issues. He indicated he went out through the same door resident #70 exited approximately between 8 and 8:25 PM, and he did not see anything out of place or anyone outside. On 7/28/23 at 9:15 AM, Activities Aide I stated she was responsible for ensuring residents in the memory care room participated and were engaged in activities. She explained there were approximately 16 residents in the memory care group. She explained the assigned CNAs brought residents to the memory care unit and they assisted residents when they needed to be changed or toileted. She stated CNAs came to check on their assigned residents or the Activities Aide called them if assistance was needed. She explained if music was on, resident #70 stayed in the memory care room listening and clapping. She indicated she noticed whenever resident #70 told her she needed to go home, it meant she needed to use the bathroom. She spoke about resident #70 exiting the facility and noted the resident could have fallen from her wheelchair while she was outside by herself or she could have been hit by a car. She was not safe to be out there by herself. On 7/28/23 at 9:47 AM, the Administrator discussed the investigation of resident #70's elopement. She explained on 7/07/23 she received a call from the ADON at approximately 9:15 PM informing her resident #70 was found outside by CNA D. She indicated she instructed the ADON to start the investigation by collecting statements from staff and she headed to the facility. She arrived at approximately 9:45 PM and saw the resident resting in bed. She explained after meeting with the staff, she met with the resident's son who had arrived at the facility. She stated resident #70 was placed on one-on-one supervision, they completed a head count of all residents in the facility, and they checked all the doors again. She noted they used resident electronic monitoring device to check all doors and all of them activated without any issues. She indicated they checked placement and function of the 5 residents who had electronic monitoring at the time, and they all worked properly. She explained LPN C had assessed resident #70 upon return to the building, with no signs of injuries or distress. She explained the second alarm technician who visited the facility on Saturday discovered the alarm malfunctioned due to a faulty wire caused by normal wear and tear. She indicated that was a high traffic door as all the deliveries came in through that door, and over time, the wires disconnected causing the alarm to work sometimes and not others. She explained the technician said it was difficult to pinpoint when the malfunction began but it was corrected the same day. She stated she reviewed the video recording from the cameras located inside and outside the facility and was able to determine when resident #70 left the building. She attempted to access the video again for the surveyors but was unsuccessful. She explained after she reviewed the video recording, she obtained clarification as there was conflicting information from the written statements from staff. She shared the timeline obtained from the video recording she reviewed: On 7/07/23 approximately before 7:00 PM, LPN C saw resident sitting quietly in her wheelchair in the hallway of the North-West Wing while passing meds. On 7/07/23 at approximately 7:00 PM, assigned CNA E saw resident in the hallway in her wheelchair. CNA E was in the memory care room while the Activities staff assigned to that area took her break. On 7/07/23 at 7:05 PM, resident left unit into the main lobby area, through unalarmed double doors. On 7/07/23 at approximately 7:08 PM, resident exited the building. On 7/07/23 at approximately 7:10 PM, Speech therapist clocked out and walked to the parking lot in the rear of the facility, but did not see resident #70. On 7/07/23 at approximately 8:20 PM, CNA E took her break, sat in the screened porch which faced the rear parking lot area. She did not see resident #70. On 7/07/23 at approximately 8:55 PM, CNA E asked LPN C whereabouts of resident #70. They began searching for the resident and received a call from CNA D that resident #70 was outside. On 7/07/23 at approximately 8:50 PM, CNA D went outside facility to take her break and saw resident #70 in the rear parking lot, behind a car. She called CNA E and informed her resident was found outside. On 7/07/23 at 9:05 PM, resident #70 returned to the facility accompanied by assigned CNA E and LPN C. On 7/07/23 at approximately 9:30 PM, LPN C performed head to toe assessment with no negative findings. On 7/07/23 at approximately 9:35 PM, LPN C called resident's son, DON and physician and reported incident. The Administrator stated during the investigation they reviewed the Elopement Risk Assessment and noted all interventions had been followed. She explained during the Ad Hoc Quality Assurance Performance Improvement Committee (QAPI) meeting they determined the root cause was the malfunction of the alarm mechanism at the exit door used by resident #70, leading to the outside of the facility. She reflected resident #70 was not safe to be outside by herself. She indicated staff was to monitor residents every 2 hours but if they exhibited exit seeking behavior, they were expected to monitor more often. She did not provide a clear definition of what more often meant. On 7/28/23 at 1:30 PM, resident #70's elopement route was retraced. Resident #70 traveled a total distance of approximately 301 feet from the Northwest Wing through the main dining room, the service corridor leading to the kitchen, the laundry and the rear parking lot where she was later found. Photographic evidence was obtained of the hazards outside the facility including a drop off to a concrete ramp within proximity to the sidewalk, broken fence, wooden pallet, uneven pavement, unlocked entrance to the trash compactor and a high voltage generator duking station. There were ramps, slopes, and stairs on the outside of the old building across the facility which resident #70 could have traversed to during the time she was outside. On 7/29/23 at 9:18 AM, the Director of Nursing (DON) explained when a CNA was assigned to the memory care area, she was not assigned residents. He stated generally residents were observed every 2 hours but if someone exhibited wandering behavior, the facility encouraged the staff to observe them more often to ensure they knew what they were always doing. He noted resident #70 would get near doors or exhibited exit seeking behavior occasionally but it was not every day. The DON stated resident #70 was to be monitored every 2 hours. He indicated the doors leading to the main dining room were left open, but they were supposed to be kept closed for staff to use their badges to access the area. He indicated residents normally did not have access to the main dining room without staff being present. He explained it was not safe for resident #70 to be out without staff supervision. He recalled he was present when the Administrator informed resident #70's son of the incident. He indicated the son was very concerned the resident got out and said they were lucky that nothing happened to her, thank God. Review of the undated document titled Supervision of Residents revealed a purpose To provide the resident with a level of supervision to meet their individual needs. The policy read, Residents are to be checked at least every 2 hours, and more often if the individual show signs of continuous exit seeking or requires a higher level of supervision due to a change in condition. Review of the Certified Nursing Assistant (CNA) job description revised on 9/16/13 revealed the essential duties of the position included to provide individualized attention, which encourages each resident's ability to maintain or attain the highest practical physical, mental, and psychological well-being. Review of the Facility Assessment updated in November 2022 revealed the facility was able to care for residents with memory care needs and continued to staff at least 1 - 2 staff members to keep the residents that need additional supervision and assistance to prevent falls . The document indicated the staff was trained upon onboarding and at least annually in how to deal with cognitively impaired residents. Review of the immediate actions implemented by the facility revealed the following, which were verified by the survey team: *On 7/07/23, at approximately 9:05 PM, resident #70 was observed outside sitting in her wheelchair in the parking area at the rear of the facility and was escorted back to the facility unharmed. LPN C completed a head-to-toe assessment and found no injuries. The physician and responsibly party were notified. *On 7/07/23, resident #70's electronic monitoring device was checked for placement and functioning against all exit doors with no issues identified. *On 7/07/23, resident #70 was placed on 1:1 observation. *On 7/07/23, resident #70's elopement risk assessment dated [DATE] was reviewed with a new one completed and noted to be consistent with the score of 18, indicating a high risk for elopement. Elopement risk assessments were reviewed and documented with no changes for 4 other residents with electronic monitoring devices. *On 7/07/23, the electronic monitoring device for the other 4 residents were checked and noted to be placed per order and functioning properly. *On 7/07/23, the care plan of resident #70 and the 4 other residents was reviewed to ensure all interventions were being followed. *On 7/07/23, a head count was completed to ensure all residents were in the facility. *On 7/07/23, all exit doors were checked two times by maintenance and security and were functioning properly and alarming when checked with the actual electronic monitoring device. *On 7/07/23, the electronic monitoring device company was contacted. In the interim and to ensure resident's safety, the door leading to the dining room was closed, and a sign posted to be kept closed/locked unless there was a supervised activity. *On 7/07/23, the physician and resident #70's family were notified. *On 7/07/23, an emergency Ad Hoc QAPI meeting was held with the Administrator, DON, ADON and the Unit Manager, and the current immediate plan was reviewed. The Medical Director was contacted via telephone and plan reviewed with him, and he agreed with the immediate plan and had no additional recommendations. *On 7/07/23, staff interviews were completed before the end of the shift. *On 7/07/23, education started and included a review of the elopement procedure, supervision of residents and enhanced supervision for residents on the electronic monitoring device program and may be increased if exit seeking behaviors observed. All staff on duty completed and staff were educated as they reported for duty on 7 AM to 3 PM and 3 PM to 11 PM shifts on 7/08/23 with remaining employees called by their immediate supervisor on 7/08/23. No staff was allowed to work if unable to reach until they received the education. 100% of active staff were educated by 7/08/23. Step by step instructions reviewed of what should be done in the event of an elopement (simulated drill). *On 7/08/23, the electronic monitoring device company performed assessment of all exit doors and identified malfunctioning door used by resident #70 to exit the facility. The door was repaired on the same day. *On 7/09/23, resident #70's elopement risk assessment was reassessed with a score of 19, indicating a high risk for elopement. Interviews were conducted with 13 facility staff including 4 CNAs, 3 licensed nurses, 3 dietary aides, 2 laundry/housekeeping aides, and 1 Activities staff between 7/27/23 and 7/29/23. Interviews revealed the facility staff received elopement education and participated in elopement drills. The sample was expanded to include 2 additional residents who were at risk for elopement. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations and care plans for residents #60 & #64.