**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy review, the facility failed to provide adequate supervision of a vulnerable resident identified to be at risk for elopement due to exit seeking, by allowing the resident to exit the facility unescorted by staff, and subsequently leave the facility grounds with a visitor unknown to the resident. This affected Resident #90 who was 1 of 2 sampled residents reviewed for accidents and supervision. The facility staff failed to intervene or report to nursing staff when the visitor reported to the receptionist that he was going to escort the resident across the street to the emergency room per the resident's request on 1/1/23 at approximately 5:50 PM. Facility nursing staff did not become aware the resident was not in the facility until approximately 7:45 PM on 1/1/23 when the resident's son called the facility to inform them she was at the emergency room receiving treatment for shoulder pain. This failure allowed the resident who had a documented diagnosis of dementia and moderate cognitive impairment to leave the facility premises with a visitor unknown to the resident, placing the resident at risk for serious injury, harm, abduction, elopement, or death. The situation resulted in a finding of Immediate Jeopardy. The facility's Administrator and the Director of Nursing were notified of the findings of Immediate Jeopardy on 1/13/23 at approximately 11:44 AM. The Immediate Jeopardy was ongoing as of the survey exit on 1/13/23. The findings include: Review of resident #90's electronic medical record revealed the resident was admitted to the facility on [DATE] and had a current diagnosis of dementia. The admission MDS (Minimum Data Set) with an assessment reference date of 11/15/22 indicated the resident had a BIMS (Brief Interview for Mental Status) score of 8, indicating moderate cognitive impairment. An elopement risk observation, documented on 11/30/22, indicated the resident was at risk for elopement with a score of 3, and proceed with safety interventions. The record revealed a current plan of care dated 12/10/22 stating the resident was at risk for elopement due to noted exit seeking and she exhibited fluctuations in level of cognition and understanding. The care plan goal included the resident's risk for elopement will be minimized through the next review date with a target date of 3/10/23. The care plan interventions dated 12/10/22 included inform staff and the resident's visitors about risk for elopement and exit seeking, monitor for verbalizations of wanting to leave, picture in elopement book, redirect and provide support when wandering or requesting to exit the facility, and report observations and concerns to physician/nurse practitioner as needed. A psychiatric progress note dated 12/28/22 revealed resident #90 had a history of dementia and presented as pleasantly confused. Progress notes reviewed over the previous 30 days noted intermittent confusion, wandering, restlessness, and placing herself on the floor. Resident limitations listed cognitively impaired and hearing impaired, alert to person and partial to date. The resident progress notes dated December 1, 2022 through January 1, 2023 revealed 14 documented observations of the resident wandering in the facility and being redirected by staff on 12/1/22, 12/2/22, 12/3/22, 12/4/22, 12/5/22, 12/10/22, 12/11/22,12/12/22, 12/22/22, 12/24/22, 12/30/22, and 1/1/23. The resident progress notes dated 1/1/23 recorded as a late entry on 1/11/23 indicated the facility was notified by the resident's son that she had left the facility and gone to the emergency room. The resident did not sign out of the facility upon leaving the facility and did not have a staff member escort her. She returned to the facility with her sons via personal vehicle. The resident was placed on one-to-one supervision due to risk for elopement. Review of the facility investigation revealed on 1/1/23 at approximately 5:45 PM employee B (former receptionist) observed resident #90 to enter the front lobby, exit the facility, and sit on a bench outside the front of the facility. She then observed the resident speaking with a visitor of another resident. The visitor then walked into the facility and stated the resident had asked to be assisted to the hospital across the street to get assistance for her arm. He stated he was going to walk her across the street, and they left the facility property on 1/1/23 at approximately 5:50 PM. The registered nurse house supervisor reported he was notified by the resident's son on 1/1/23 at approximately 7:45 PM that she had left the facility and gone to the emergency room. Review of the facility investigation and staff statements of the event revealed prior to the event the resident had asked a staff member to go home while she was ambulating the halls on 1/1/23, and the resident was observed going to the doors looking for a way to get outside on 1/1/23. An interview was conducted with the Director of Nursing (DON) on 1/12/23 at 2:43 PM. She stated the visitor was at the facility to visit another resident. She called that resident's sister, and she did not have any contact information for the visitor. A telephone interview was conducted with employee B (former receptionist) on 1/12/23 at 3:16 PM. Employee B stated resident #90's picture was not in the elopement book at the time of the event on 1/1/23 and refused to answer further questions regarding the event. A telephone interview was conducted with the resident's son on 1/12/23 at 3:25 PM. He stated the resident was in the hospital, had just had surgery, and was being placed on hospice for terminal care. An interview was conducted with the DON on 1/13/23 at 9:56 AM. The DON stated the resident tailgated with a group of visitors out the front lobby door when the receptionist unlocked the front lobby door for the visitors to exit. The DON clarified the resident exited both sets of doors at the lobby, the door that enters the lobby and the door that exits the building. The resident exited via the front door with the group of visitors and the receptionist had to unlock both doors for the resident and group to exit, then the resident sat on the bench outside the front door. Further interview was conducted with the DON on 1/13/23 at 10:04 AM. The DON stated the facility determined the root cause of the event was staff did not follow process and should have redirected the resident back into the facility. The facility had no evidence to support the resident knew the visitor that escorted her to the emergency room (ER). The visitor came in and asked the receptionist if he could take resident #90 across the street to the ER and the receptionist said yes. She stated the resident's photo was in the elopement book at the time of the event and the receptionist acknowledged she was aware of the resident's picture being in the elopement book. The DON stated the only policy the facility had that covers the resident sign out procedure is the transfer or discharge policy stating they would provide verbal or written notice of intent to leave and there is not a specific policy of who can sign the resident out of the facility. Review of the facility policy Transfer and Discharge (effective date 11/1/18) revealed therapeutic leave is a type of Resident-initiated transfer. A Resident-initiated transfer or discharge is one in which the Resident has provided written or verbal notice of their intent to leave the facility, which is documented in the Resident's record. A Resident's expression of a general desire to return home or to the community or elopement of a Resident who is cognitively impaired will not be taken as a notice of intent to leave. Review of the facility policy for Resident Elopement Risk Management Guidelines (revised 1/12/2020) revealed the facility will strive to provide a safe environment for residents and implement measures to identify residents at risk for elopement, as well as preventative measures to minimize elopement occurrences. The policy defines elopement as: An elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Page 2 number 6 of the policy indicates when a a resident is observed to be wandering to an unsafe situation or exiting the facility, the nearest staff should intervene or summon help if unable to safely manage the event. If wandering behavior escalates, safety checks should be implemented, and the resident should be evaluated for possible cause and new interventions implemented as needed.