**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a secure environment to prevent an elopement for a resident with dementia and documented wandering and exit-seeking behavior, for 1 of 3 sampled residents reviewed for elopement, Resident #134. The resident eloped from the facility on 03/07/23 between 2:20 PM and 2:30 PM and was returned to the facility by a 'passerby' after being located in the community near the facility at 2:30 PM. It was unknown by facility staff and management precisely where Resident #134 was located. Upon being returned to the facility, Resident #134 was placed in the Memory Care Unit (secured unit). Upon assessment after being returned to the facility, Resident #134 was not harmed and showed no signs of distress. The facility's failure to adequately supervise and provide a secure environment for Resident #134, who was identified as an elopement risk, resulted in the finding of Immediate Jeopardy, past noncompliance on 03/07/23. The Immediate Jeopardy was determined to be corrected on 03/17/23, prior to the survey based on survey verification of compliance with the facility's corrective plan. The findings included: The facility's policy, titled, Missing Resident Code Purple Elopement Policy and Procedure, updated 02/11/19, documented, in part: Policy: All residents will be assessed for elopement risk in order to maintain his/her safety. (To be done upon admission/readmission and as deemed necessary, i.e. behavior changes.) Addendum to Missing Resident Policy and Procedure: The definition of elopement will be defined for the purpose of this Policy and Procedure as follows; Any absence that is not previously authorized by or communicated to the Solaris Healthcare Parkway staff, and results in a resident leaving the premises or a safe area of the center without necessary supervision and puts the resident at risk for harm or injury. Or any absence by a resident living int the center's Memory Care Unit without authorization and/or necessary supervision that puts the resident at risk for harm or injury. The facility's policy for Doors, documented: Ensure that automatic or self-closing devices are properly installed and functioning. Monitor doors with magnetic locks or delayed egress locks to ensure that: Doors release appropriately at preset time delay and upon activation of the fire alarm system. No more than one delayed egress locked door is in the path of travel. Doors with magnetic locking devices unlock upon activation of the fire alarm system. Doors do not reactivate if the fire alarm system is placed in silent mode. The doors should not relock without the system being reset. Systems are returned to working order after performance of maintenance. The department is contacted to obtain any required approval before changes are made to the system. Resident #134 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #134 had a Brief Interview for Mental Status score of 07, indicating severe cognitive impairment. The assessment documented that the resident did not exhibit wandering behaviors during the 7-day look back period and required limited assistance and one person physical assist for Activities of Daily Living, including bed mobility, transfer, walk in room, walk in corridor, locomotion on and off of unit, and toilet use. The assessment documented that the resident was 'occasionally incontinent' of urine and 'frequently incontinent' of bowel. The assessment documented that Resident #134 ambulated via the use of a wheelchair. Resident #134's diagnoses at the time of this assessment included: Hypertension, Neurogenic Bladder, Urinary Tract Infection (UTI) (within the last 30 days), Hyponatremia, Hyperlipidemia, Alzheimer's disease, Malnutrition, Anxiety disorder, Depression, Dementia, Hypo-osmolality, Chronic pain, Nonrheumatic mitral prolapse, Chronic gastric ulcer, disorders of bone density, repeated falls, Retention of urine, restlessness, and agitation. An Elopement Risk Assessment was completed on 10/13/22 for Resident #134. The Assessment documented that Resident #134 was independently ambulatory, verbally expressed 'desire to leave center or go home', cognitively impaired with poor decision-making skills, had indications of dementia or a diagnosis of dementia, and short-term stay changed to long term care. The assessment documented that Resident #134 was not an elopement risk. An Elopement Risk Assessment was completed on 01/04/23 for Resident #134. The Assessment documented that Resident #134 exhibited wandering or exit seeking behavior in the last 90 days, was independently ambulatory, exhibited new behavior that would cause concern related to wandering exit seeking or safety, verbally expressed 'desire to leave center or go home', was cognitively impaired with poor decision making skills, had visual and auditory deficits, had indications of dementia or a diagnosis of dementia. The Assessment documented, the patient is a risk for elopement. Proceed with appropriate safety intervention and Resident had UA C&S [urinalysis / culture and sensitivity] done due to new behaviors and was diagnosed and treated for UTI. Behaviors stopped with treatment. Family in daily to visit and is aware of behaviors and the cessation of behaviors with treatment for UTI. Resident #134 successfully exited the facility, without staff knowledge, on 03/07/23 between approximately 2:20 PM and 2:30 PM. The resident was returned to the facility at 2:30 PM. Prior Elopement Risk Assessments concluded Resident #134 was not at risk for elopement and resided on the 200-hallway, approximately in the middle of the unit between the nurses' station and the emergency exit door at the end of this unit. Prior to the elopement, Resident #134 did not have a care plan for wandering and/or elopement risk and resided on the 200 Unit, which was not a secured unit, and supposedly exited through the emergency exit that was not secured, at the end of the unit. During the survey process of 03/20-24/2023, it was determined that Resident #134 was not interviewable as evidenced by not being able to provide appropriate answers regarding the event/incident. A Nursing Home Adverse Incident Report, submitted to the Agency on 03/21/23, documented the following: Resident is an 83 y/o [year old] long term resident admitted on 12.23.21. On 03.07.23 at approximately 2:05-2:15 pm, resident was observed by [name] Administrator and [name] EVS [Environmental Services Director], sitting across from North Wing 200-Hall nursing station [where she resides] with another female resident - both holding a recent copy of the weekly menu selections. At approximately 2:30 pm, Administrator had returned to front lobby office and was alerted that resident had been observed and redirected back to facility by a passerby familiar with Solaris Campus. Administrator immediately went to front entrance and saw that resident was sitting in the vehicle backseat of the visitor, still holding her weekly menu. Resident was smiling, and appeared to be in no distress, nor discontent. No injuries were noted and no c/o pain. Administrator [NHA] accompanied resident back into the center and DON [Director of Nursing] then escorted her to the MCU [Memory Care Unit] for safety. She joined the activity being conducted. Elopement Assessment was completed and resulted in a score of four (4) at risk for elopement. Decision was made by Nursing leadership in conjunction with Administrator to transfer resident to Secured Memory Care Unit for environmental safety; discussion was had with resident's daughter [name] and informed consent obtained. Attending physician [Name] was notified at approx. [approximately] 3:00pm and new orders for lab testing were received. [The] 200-Hall charge nurse, [Name] LPN [Licensed Practical Nurse], conducted a manual census verification (head count) to confirm all residents were accounted for. A Center-wide audit was conducted to ensure all emergency exit doors remained secured and properly alarmed. QAPI [Quality Assurance and Performance Improvement] AD HOC Meeting was called and attended by NHA, DON, Risk Mngr. [Manager], and Medical Director (by phone). Medical Director review and initiated event investigation. Resident's Hallway Emergency Exit door magnetic locking mechanism was unlocked and dis-alarmed, where resident likely exited independently from the center without notification. Plant Operations Director [Name] had temporarily unlocked the 200-Hall Exit door, (adjacent to HVAC installation project, on 100-Hall/Memory Care Unit) on 03.07.23 in order to increase accessibility of outdoor equipment and supplies for contractor, with minimal disruption to facility residents. Plant Ops. Director had not considered potential of resident exiting the wing through the emergency exit door. Resident ambulates ad lib on the hallway, independently. On the Event Details Note, dated 03/07/23 at 2:30 PM, the DON documented, Resident was observed walking outside the center and was quickly returned and redirected back to the Center's North Wing. Resident has no injury, and no distress noted. Elopement Assessment was conducted by Charge Nurse and resulted in a score of 4 at risk for elopement. Resident was transferred to Memory Care Secured Unit. On 03/22/23 at 8:20 AM, Resident #134 was observed being taken to the shower room by staff, it was noted that Resident #134 was ambulating without the use of assistive devices (e.g. wheelchair, walker). It was noted that resident walked slowly, in small shuffling steps. On 03/22/23 at 8:22 AM, during an interview with the ADON (Assistant Director of Nursing), when asked about Resident #134 ambulation, the ADON stated the resident was ambulatory without the use of assistive devices. During interviews with the nursing staff and the Administrator on 03/23-24/23, they reported that there were no video cameras on the unit that they were aware of. During an interview, on 03/22/23 at 9:16 AM, with Staff B, LPN, when asked about Resident #134's behavior, Staff B replied, She would walk up and down the hall, she would ambulate herself. I am not sure if she was exit seeking. Sometimes she would go to the door to the dining room and sit there. The family comes and takes her out in the mornings. The daughter would come every day about 9:00 or so with the resident's husband and they would be outside for a while and sit for a while and come back. She would spend about 2 hours with her outside on the porch [between the 100-200 Dining room and the lobby / reception area at the main entrance to the facility]. On 03/22/23 at 9:50 AM, the alarm was heard sounding at the Emergency Exit at the end of the 200 unit. When asked about the alarm, Staff C, Plant Operations Assistant, stated, I was making sure the alarm on the door was set and not off. The alarm indicates that the door has been opened. I am going through all of the hallways and checking all of the exit doors. Every day in the morning and before I leave at night, I leave at 5:30 [PM], I usually do it at 5:15-ish [PM]. During an interview, on 03/22/23 at 9:52 AM, with Staff D, LPN (Nurse on day of 03/07/23 and previous day), when asked about Resident #134's behaviors, Staff D replied, she does walk back and forth in the hallways and would walk all the way up to the dining room - it is always closed. She usually does it after lunch and we have her sit with us, and sometimes she would go back to her room. One of her daughters comes almost every day after lunch. She wasn't exit-seeking, just wandering. I have never seen her at the end of the unit and have not seen her touch that door. When asked about the door that Resident #134 exited through, Staff D, stated that the resident exited through the emergency exit at the end of the 200 unit. When asked where Resident #134 was going, Staff D replied, I was helping a nurse on the 100 hallway and by the time that I finished that, somebody was returning [the resident] after she got out the door. They told me that she was found on the street in front of the facility (Central Parkway). Not positive which side of the road. When asked about Resident #134 being ambulatory, Staff D replied, She had a wheelchair for a little bit when she came in. Since then, she has been independently ambulatory without assistive devices. When asked of Resident #134's cognition, Staff D stated, alert (to person and place) with confusion. On 03/22/23 at 10:02 AM, Resident #134 was observed by this surveyor being escorted from the memory care unit by her daughter to the patio with her husband. It was noted that Resident #134 was walking without the use of assistive devices and was taking small shuffling steps. During an interview, on 03/22/23 at 10:10 AM, with Staff E, CNA (Certified Nursing Assistant), who was the CNA on the day of the elopement and previous day, when asked about the incident, Staff E replied, That day she was with the menu and was sitting by the nurse's station. I walked to the TV room to get help with putting a resident in bed, when I came back, I was told that she went out. She walks back and forth on the unit, but never tried to get out or approached the door to my knowledge. During an interview, on 03/22/23 at 10:20 AM, with Resident #134's husband and daughter, when asked about the elopement, Resident #134's daughter replied, They left the door unlocked as they were doing some work and she was found on Central Parkway. Somebody drove by and said that she looked lost and asked if she knew where she was going and brought her back. They called me at home and told me that. They immediately called me and told me about it. I didn't see any construction on the 200 hall. During an interview, on 03/22/23 at 10:38 AM with the Director of Nursing (DON) when asked about the incident and where and when the resident was found, the DON replied, there was a passerby that was a caregiver that brought her back, the Administrator was involved in that part of it. I put her in the Secured Memory Care unit. She scored a 04 on the Elopement risk. Her daughter did not want her to go to the memory care unit. We explained that it was the safest place for her, and she was not happy with that decision. They were doing work on the air conditioning unit on the 100 unit and the door was unlocked for the workers to go in and out, at which time we did not know. She was found on Central Parkway. When Resident #134 first came in, she was wandering and was very confused and on the Memory Care Unit. The daughter was very against it. She wasn't trying to exit seek and didn't go near the door. If they are not exit seeking, we will move them out of the unit. She would never even go out of the double doors without the daughters being here. If we would have known that the door was open, we would have put a fire watch at the door. The Plant Operations Director is new to the position and didn't realize that was not the Memory Care unit. We checked all of the doors and did a head count. One hundred percent (100%) of the facility in-serviced on elopement, door codes, reporting, abuse a focused meeting was scheduled and that was our first one. My ADON and myself went and re-did all of the elopement assessments again to make sure that they were correct - 147 patients were re-evaluated. We QAPI it and we double checked all of the assessments and they were all accurate. We did elopement drills on a Sunday with the Risk Manager and on Friday evening prior to that. The RM (Risk Manager) is checking all of the doors every morning as well as Maintenance doing it and keeping a log. I checked in with the daughter. We did some lab work on her and was found with no infections. During an interview, on 03/22/23 at 10:53 AM, when asked how Resident #134 was found and returned to the facility, the Administrator replied, She was observed by someone driving towards SE Central Parkway, I had just seen her and noticed her, and I had sent a text to [Name] the Plant Operations Director about the shower room and then heard somebody yelling at the receptionist. What happened was a transport company had driven up to pick up a resident for an appointment and said that 'I think I may have seen one of your residents and the transport company yelling to the receptionist. She was right out here (referring to the main entrance of the facility).' When she was first admitted , she was admitted as short term on 12/24/21, was unsafe wandering and they did an elopement assessment and scored high, and we moved her to the memory care unit for about a month until we did another assessment and she did not display the same wandering behaviors. She was doing very well. We did another assessment after the elopement and she scored a 4, which was high, she had a UTI, we will continue to reassess her and if she doesn't show exit seeking, then we will try to transfer her to a less restrictive environment. [Name] (the passerby) asked her where she was going and she said, 'to find her husband' and told her 'I'll take you there and brought her to the facility. During further interview, when asked where the resident was found by the passerby, the Administrator stated that she was unable to confirm where the resident was found, as she did not get details from the passerby, and did not have contact information for that person. During an interview, on 03/22/23 at 1:02 PM with the Plant Operations Director, when asked about the door not being secured, the Plant Operations Director replied, The actual work started about 2 weeks ago. The portable unit was bought for hurricane reasons, we bought 3 or 4 of them about 5 years ago. They were coming in and out for the attic, the insulation, and the tools, this was one of the days where I had one guy. I told the nurse that they were going to be coming in and out and that the door was not armed - (Staff D) She said 'okay', she might have said I'll keep a look out or something, but it wasn't much more than that. When asked about how long the door was unsecured, the Plant Operations Director replied, they got here around 1 PM and started bringing in their stuff. It was open until about 3:00 or so, and I left at 4:30 PM. The facility's actions to remove the Immediate Jeopardy and correction action plan prior to the survey included: 1. Resident #134 was assessed for elopement risk and moved to the secure Memory Care Unit. 2. All emergency exits were checked and found to be secured. 3. Staff D/LPN, Staff E/CNA, the Plant Operations Director and the contractor were in-serviced regarding securing the emergency exits. 4. Elopement risk assessments were completed for all resident not residing on the secured Memory Care Unit on 03/10/23. 5. An Ad Hoc QAPI meetings held on 03/07/23, 03/09/23, and 03/17/23. Interviews during the survey with NHA, DON and President of Solaris revealed management realized the focus of the event as per the RCA should be on environmental and door safety along with education. Initiation of twice daily door checks continued, and education began. They also realized doing daily elopement drills on all shifts was not effective due to disruption to resident care needs and routine, and again as this was not the root cause. This was again discussed and documented at the AD HOC/QAPI meeting of 03/09/23. 6. Emergency exit doors (13) checked daily for function by Plant Operations and Risk Management 7. 100% of staff provided in-service completed as of 03/12/23. 8. Elopement Drills conducted 03/10/23, 03/12/23 and 03/23/23 and are scheduled through August 2023. The survey team verified the corrective actions were implement and completed as evidenced by: 1. AD Hoc QAPI meeting minutes were reviewed for meetings conducted on: a. 03/07/23 b. 03/09/23 c. 03/17/23 d. 03/23/23 2. The facility provided documentation of audits of the emergency doors, twice daily from 03/07/23 and are ongoing. 3. On 03/23/23 at 7:30 AM, this surveyor toured the facility with the Risk Manager and found all 13 doors were secured and functioning properly. 4. Random staff interviews were conducted on 03/22/23 with 4 CNAs and 1 LPN who confirmed in-service training. Surveyors' interviews conducted on 03/22 through 3/24/23 with at least one staff from each department, including nursing, therapy, social services, activities, housekeeping, laundry, maintenance, and dietary; and on each shift were conducted to confirm education. 5. Documented in-services trainings were completed for staff, between 03/08/23 to 03/12/23, included: - 76 of 76 CNAs - 27 of 29 Therapy staff (2 staff were per diem and have not worked since the elopement) - 21 of 21 LPNs - 13 of 13 RNs - 13 of 13 Housekeeping staff - 4 of 4 Laundry staff - 16 of 16 Dietary staff - 3 of 3 Medical Records staff - 10 of 10 Administrative staff - 3 of 3 Activities staff - 6 of 6 Social Services staff - 8 of 8 Nursing Administrative staff - 1 of 1 contracted Beautician - 1 of 1 ARNP (Advanced Registered Nurse Practitioner) 6. Documentation of Elopement Drills was provided for drills conducted on: - 03/10/23 - for the 11:00PM to 7:00 AM staff - 03/12/23 - for the 7:00 AM to 3:00 PM staff and 3:00 PM to 11:00 PM staff - 03/23/23 - for the 3:00 PM to 11:00 pm staff and the 11:00 PM to 7:00 AM staff - Drills are scheduled every 2 weeks through the month of August 2023. No residents were observed wandering or displaying exit-seeking behaviors outside of the secured Memory Care Unit for the duration of the survey - 03/20/23 to 03/24/23. Immediate Jeopardy was determined to be past noncompliance and corrected on 03/17/23, prior to the survey.