**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility neglected to provide appropriate care and services to prevent a fall with major injury for a vulnerable and physically impaired resident, during a transfer with a mechanical lift and failed to complete a thorough investigation after a fall with major injury for 1 of 6 residents sampled for falls, (#197). On 2/08/24 at approximately 6:00 PM, the facility failed to prevent a fall with major injury during a transfer with a mechanical lift. The facility failed to utilize the appropriate type of mechanical lift and failed to follow policy requiring two staff for mechanical lift transfers. While Certified Nursing Assistant (CNA) G transferred resident #197 by herself from chair to bed using the wrong mechanical lift, the resident became unstable and was manually lowered to the floor. The resident complained of pain and x-rays done at the facility identified a fractured left clavicle, (A clavicle fracture-collarbone, is diagnosed through physical examination and x-rays. Symptoms of a broken collarbone include severe pain and swelling at the site of the fracture with visible deformity in some cases. Because of the critical location of the clavicle, any severe force on the shoulder such as falling directly on the shoulder or falling on an outstretched arm transfers force to the clavicle . retrieved from www. hopkinsmedicine.org on 2/20/24). She was transferred to the hospital on 2/09/24 for further scans and returned the same day with confirmed fractured left clavicle. The facility's failure to provide safe and appropriate care when using mechanical lifts placed all 41 residents who required a mechanical lift for transfers at risk for serious injury/impairment/death and resulted in Immediate Jeopardy starting on 2/08/24. The facility's Administrator, Director of Nursing (DON), and Corporate Clinical Nurse were notified of the Immediate Jeopardy on 2/15/24 at 3:17 PM and provided the IJ templates. The Immediate Jeopardy was determined to be removed on 2/16/24 after verification of the immediate actions implemented by the facility. The scope and severity of the deficiencies was decreased to a D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy Findings: Cross reference to F689 Resident #197, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, asthma, atrial fibrillation, chronic obstructive pulmonary disease, diabetes, obstructive sleep apnea, obesity, and muscle weakness. On 2/09/24, unspecified left clavicle fracture was added to her diagnosis. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date 2/05/24 revealed the resident's cognition was intact, with a Brief Interview for Mental Status score of 15 out of 15. The assessment noted resident #197 had adequate hearing, clear speech, understood, was understood, and had adequate vision. The assessment indicated the resident was independent for eating, oral hygiene, and personal hygiene, but required partial/moderate assistance for showers and upper body dressing, substantial/maximal assistance with rolling left to right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair to bed/bed to chair, and dependent for toileting hygiene, and lower body dressing. The assessment also revealed the resident had no impairment to upper or lower extremity range of motion and used a wheelchair for mobility. The assessment indicated resident #197 had no behaviors toward herself or others. On 2/12/24 at 5:17 PM, resident #197 spoke about the incident that occurred on 2/8/24 at 6:00 PM. She stated Certified Nursing Assistant (CNA) G was putting her back to bed from her wheelchair using the sit to stand mechanical lift. The resident said CNA G was attempting the transfer alone and she told the CNA she needed two staff to transfer with the lift. The resident recalled CNA G told her, Don't tell me how to do my job. The resident explained she knew it had to be two staff to use the lift because the physical therapist had instructed another CNA on day shift with the sit to stand mechanical lift and told her it always had to be two staff. That is why I told the CNA it should be 2 people. Resident #197 continued, When I was in the lift, I told the CNA something did not feel right but she walked around to the side of the lift and the next thing I remember, I was on the floor looking up at my nurse. She stated she had pain in her left shoulder now and explained she had to stay in the facility longer as she was not able to do therapy because of the fracture. On 2/13/23 at 10:47 AM, in a telephone interview, Registered Nurse (RN) E stated CNA G was with resident #197 when she called out to him for help. He said when he went in the room, the resident was in the sit to stand mechanical lift sliding down and falling towards the floor. He recalled he tried to help CNA G but resident #197 was too heavy for two staff to lift. He said he called CNA F to come to the room to assist. RN E said the three of them managed to put her on the floor . He stated after the resident was on the floor, CNA F and G went to get the full body mechanical lift and the two CNA's transferred the resident back to her bed. RN E reiterated CNA G was in the room transferring the resident by herself when she called out to him for help. Review of nursing progress note dated 2/09/24 at 12:02 AM, by RN E read, At the time of the incident CNA would call me for help since she was using the stand lift, and the resident was in an unstable position and was kneeling towards the floor. I never crash to the ground. We had to put her on the floor for her safety. We lift her in the 'full body mechanical' lift and transfer her to the bed. On 2/13/24 at 11:13 AM, in a telephone interview, CNA G stated when she went in resident #197's room she was seated in her wheelchair. In conflict with resident #197's and RN E's statements, CNA G stated she and CNA F used the sit to stand mechanical lift to put resident #197 back to bed. CNA G then described resident #197 moved her hands from the hand bar so she called the nurse for assistance. CNA G stated the three staff (herself, RN E and CNA F) took resident #197 off the sit to stand mechanical lift and put her on the floor. CNA G added that she went to get the full body mechanical lift after the nurse, RN E came to the room and she and CNA F transferred the resident back into bed. On 2/14/24 at 9:30 AM, in contradiction to resident #197 and RN E's statements, CNA F stated she was in the room with CNA G to help transfer resident #197 back to bed. She explained, we went in to transfer her from the chair to the bed. CNA F stated she put the sling behind resident #197's back and was hooked the sling to the sit to stand mechanical lift when the resident moved her arm. CNA F stated the resident started to slide down and she and CNA G put her on the floor. CNA F said, The resident was already down on the floor when we called RN E. She stated the RN E came to the room and was told the resident was placed on the floor from the lift. She noted RN E checked the resident for injuries and then she and CNA G transferred the resident to bed using the full mechanical lift. Review of the x-ray done at the facility on 2/08/24 at 7:00 PM, showed the results were reported to the facility at 8:14 PM, with findings of a new non-displaced clavicle fracture. Review of the medical record indicated resident #197 was sent to the hospital on 2/09/24 due to continued pain in her shoulder. The results of the x-ray taken at the hospital on 2/09/24 at 12:46 PM indicated resident#197 had an angulated, nondisplaced fracture of the distal left clavicle. On 2/14/24 at 1:53 PM, Physical Therapy Assistant (PTA) I stated resident #197 was motivated on the first week of therapy because she wanted to go home. He explained that due to the fracture, the resident had pain and could not use her left arm so her therapy had to be extended. PTA I said resident #197 previously required moderate assistance for bed mobility but now required maximum to total assistance due to pain. He stated resident #197 told him there was only one person using the lift with her and she knew it was supposed to be two people. PTA I said, I also heard that it was one person using the mechanical lift with resident #197. Review of the care plan and [NAME] revealed resident #197 was assessed to require two-person assist for transfers. There was no indication on either the care plan or the [NAME] as to the type of device needed to transfer the resident until 02/08/24, when the care plan was revised to indicate the resident required use of a full body mechanical lift for transfers. On 2/15/24 at 12:15 PM, the Corporate Nurse explained a two-person transfer, required two staff to be involved in the process of the transfer. She stated this indicated the number of staff required to safely transfer a resident but did not describe what type of lift was to be used. The Corporate Nurse explained the care plan did not detail the type of lift needed to transfer resident #197 until 2/08/24. On 2/13/24 at 8:40 AM, resident #197 stated police officers came to see her last night. The resident stated she was not sure why they were there. She stated they said they were here to see how she was doing but didn't really say much more than that. On 2/13/24 at 10:00 AM, the Administrator stated he called the police and Department of Children and Family (DCF) because resident #197 alleged neglect concerning her fall on 2/8/24. He stated he had not reported the incident to the State Agency as he was still investigating. On 02/15/24 at 5:33 PM, resident #197 stated someone came to her room today and told me she had spoken to me before. The resident explained this person did not introduce themselves when they came to her room. She said this person recounted incorrect information about the incident on 2/08/24. The resident said, this person told me that I had said I had pulled myself up in bed, heard a pop, and that caused the fracture in my shoulder. The resident was visibly upset and noted, I told her I have never said that to you. I don't know where you got that from. On 2/16/24 at 1:50 PM, CNA M spoke about resident #197's transfer needs. I personally would not feel comfortable using a sit to stand with her because she is very dependent on help with any movement. When I took care of her before and after the incident, she was not able to pull herself up in bed. I went into the room at least two to three times during my shift to pull her up in bed and it always took two people. On 2/15/24 at 12:15 PM, an interview was conducted with the Regional Nurse Consultant, the Director of Nursing (DON) and the Administrator. The Nurse Consultant explained that two person assist with transfers meant that two staff should be present to do the transfer. She described it could be for a standing lift or full mechanical lift transfers. She stated two person assist only indicated the number of staff, not the type of mechanical lift to be used. She acknowledged the type of mechanical lift was not reflected on resident #197's care plan until 2/08/24. The Administrator added, in the morning meeting, the Minimum Data Set Nurse inputs any changes to the care plans and [NAME]. He explained after the meeting, any changes would be communicated to the CNAs verbally. He said the type of lift to be used for resident #197 should have been in the electronic system as a task but explained it did not get written in the [NAME] until 2/8/24. He did not clarify if the specific lift was added prior to the incident or after the incident. The Administrator reported the wrong mechanical lift was used for the resident as she did not like the full body mechanical lift and the CNA said she had used the sit to stand mechanical lift previously with the resident. When asked if CNAs determined the type of lift to use to transfer residents, the Administrator did not provide an answer. They were asked to clarify the inconsistencies in statements from the both the resident and RN E who stated only one CNA transferred the resident and CNAs G and F's statements that it was 2 CNAs. The Administrator replied he was told two CNAs transferred the resident. The Abuse, Neglect and Exploitation policy most recently revised 11/16/23 read, Neglect means failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility policy, Safe Resident Handling/Transfers implemented 11/03/2020 and revised 11/29/22 read, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident. Two staff members must be utilized when transferring residents with a mechanical lift. Review of the CNA job description included duties to ambulate and transfer residents utilizing appropriate assistive devices and body mechanics. The resident sample was expanded to include five additional residents who were identified as requiring a mechanical lift for transfers. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 2-09-24, staff members involved were given 1:1 education by the Staff Development Coordinator on the proper use of mechanical lifts. * On 2-09-24 through 2-15-24 current nursing staff and therapy staff were educated on the transfer of residents and the use of the mechanical lifts by the Director of Nursing, Staff Development Coordinator and Nurse managers. Twenty five nursing staff members were educated on 2-09-24, 8 nursing staff members were educated on 2-12-24, 5 nursing staff were educated on 2-13-24, 1 nursing staff was educated on 2-14-24, 50 staff members were educated on 2-15-24. Newly hired staff members and agency staff will be educated during the orientation process. Staff members that are on vacation will receive education prior to the start of their next shift. * On 2-12-24 through 2-15-24 current staff were educated on ANME (Abuse, Neglect, Misappropriation, Exploitation) by Staff Development Coordinator, Nurse Managers and Department Heads. On 2-12-24, 18 facility staff members were educated, on 2-13-24, 17 facility staff members were educated, and on 2-15-24, 89 staff were educated. Newly hired staff members and agency staff will be educated during the orientation process. Staff members that are on vacation or FMLA will receive education prior to the start of their next shift. * On 2/16/24, out of 88 Total nursing and therapy employees-77 nursing and therapy employees received education on the use of the mechanical lifts. * On 2/16/24, out of 124 Total facility employees, 103 Facility staff received education on ANME. * Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held on 2-16-24 with Medical Director, Administrator, DON, Staff Development Coordinator, Therapy Director, and Unit Manager to discuss transfer status, mechanical lift use and root cause analysis. Interviews conducted from 2/17/24 with 13 facility staff including licensed nurses and CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan and [NAME] to identify number of persons and mode of transfer or which mechanical lift for resident transfers. They verified a return demonstration was completed after the education. They confirmed they received Abuse/Neglect education followed by a post test.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to prevent a fall with major injury for a vulnerable, physically, impaired resident, and failed to ensure the correct procedure was followed when using a mechanical lift to transfer residents for 1 of 6 residents sampled for falls, out of a total sample of 45 residents, (#197). On 2/08/24 at approximately 6:00 PM, the facility failed to prevent a fall with major injury during a transfer with a mechanical lift. The facility failed to utilize the appropriate type of mechanical lift and failed to follow policy requiring two staff for mechanical lift transfers. While Certified Nursing Assistant (CNA) G transferred resident #197 by herself from chair to bed using the wrong mechanical lift, the resident became unstable and was manually lowered to the floor. The resident complained of pain and x-rays done at the facility identified a fractured left clavicle, (A clavicle fracture-collarbone, is diagnosed through physical examination and x-rays. Symptoms of a broken collarbone include severe pain and swelling at the site of the fracture with visible deformity in some cases. Because of the critical location of the clavicle, any severe force on the shoulder such as falling directly on the shoulder or falling on an outstretched arm transfers force to the clavicle . retrieved from www. hopkinsmedicine.org on 2/20/24). She was transferred to the hospital on 2/09/24 for further scans and returned the same day with confirmed fractured left clavicle. The facility's failure to provide safe and appropriate care when using mechanical lifts placed all 41 residents who required mechanical lift for transfers at risk for serious injury/impairment/death and resulted in Immediate Jeopardy starting on 2/08/24. The facility's Administrator and Director of Nursing, and Corporate Clinical Nurse were notified of the Immediate Jeopardy on 2/15/24 at 3:17 PM, and provided the IJ templates. The Immediate Jeopardy was determined to be removed on 2/16/24 after verification of the immediate actions implemented by the facility. The scope and severity of the deficiencies was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy. The census at the start of the survey was 93. Findings: Cross reference to F600 Resident #197, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, asthma, atrial fibrillation, chronic obstructive pulmonary disease, diabetes, obstructive sleep apnea, obesity, and muscle weakness. On 2/09/24, the diagnosis of fractured left clavicle was added. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 2/05/24 revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The assessment noted resident #197 had adequate hearing, clear speech, understands, was understood, and had adequate vision. The assessment indicated resident #197 was independent for eating, oral hygiene, and personal hygiene. She required partial/moderate assistance for showers and upper body dressing, substantial/maximal assistance with rolling left to right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair to bed/bed to chair, and was dependent for toileting hygiene and lower body dressing. The assessment also revealed resident #197 had no impairment to her upper or lower extremities and used a wheelchair for mobility. The assessment indicated the resident had no behaviors towards herself or others. On 2/12/24 at 5:17 PM, resident #197 stated CNA G had put her back to bed from her wheelchair using the sit to stand mechanical lift on 2/08/24. The resident explained CNA G was in the room getting ready to transfer her by herself and she told the CNA she needed another person to help. Resident #197 said CNA G's response was Don't tell me how to do my job. The resident recalled, When I was in the mechanical lift, I told CNA G something did not feel right but she walked around to the side of the lift and the next thing I remember was being on the floor looking up at my nurse. A sling was observed on the resident's overbed table. She stated she had pain in her left shoulder now and explained she had to stay in the facility longer as she was not able to do therapy because of the fracture. She stated the fractured shoulder had set her back in her progress with therapy and delayed her discharge to home. Review of the x-ray done at the facility on 2/08/24 at 7:00 PM, showed the results were reported to the facility at 8:14 PM, with findings of a new non-displaced clavicle fracture. Review of the medical record indicated resident #197 was sent to the hospital on 2/09/24 due to continued pain in her shoulder. The results of the x-ray taken at the hospital on 2/09/24 at 12:46 PM indicated resident#197 had an angulated, nondisplaced fracture of the distal left clavicle. On 2/13/23 at 10:47 AM, during a telephone interview, Registered Nurse (RN) E stated CNA G was providing care to resident #197 and called out to him for help. The RN stated when he went in the room, CNA G was in the room alone. He recalled the resident was in the sit to stand mechanical lift in what looked like an unsafe position. He described the resident's knees were going toward the floor like she was going to fall. He said he called CNA F to the room to assist and they held the resident and lowered her to the floor. He reiterated only one CNA, CNA G was in the room when he was called to the resident's room. On 2/13/24 at 11:13 AM, in a telephone interview, CNA G stated when she went in resident #197's room, she was seated in her wheelchair. In conflict with resident #197's and RN E's statements, CNA G stated she and CNA F used the sit to stand mechanical lift to put resident #197 back to bed. CNA G then described that resident #197 moved her hands from the hand bar, became unstable, so she called RN E for assistance. CNA G stated the three of them, herself, RN E and CNA F took resident #197 off the sit to stand mechanical lift and held her to put her on the floor. CNA G added, she went to get the full body mechanical lift after RN E came to the room and she and CNA F transferred the resident back into bed. On 2/14/24 at 9:30 AM, during an interview, CNA F stated she was in the room with CNA G to help transfer resident #197 back to bed. She explained she put the sit to stand lift sling behind resident #197's back and hooked the sling to the lift machine when the resident moved her arm. She reported the resident became unstable and started to slide down and the two of us put her on the floor. CNA F stated she was sure the resident was already down on the floor when we called RN E. CNA F stated it was herself and CNA G that put the resident on the floor after she started to slide from the lift. She repeated the nurse, RN E was called to the room after they had lowered her to the floor. On 2/15/24 at 12:15 PM, the Corporate Nurse explained a two-person transfer, required two staff to be involved in the process of the transfer. She stated this indicated the number of staff required to safely transfer a resident but did not describe what type of lift was to be used. The Corporate Nurse explained the care plan did not detail the type of lift needed to transfer resident #197 until 2/08/24. Review of the resident's care plan and [NAME] revealed resident #197 was assessed to require two-person assist for transfers. There was no indication on either the care plan or the [NAME] as to the type of device needed to transfer the resident until 02/08/24, when the care plan was revised to indicate the resident required use of a full body mechanical lift for transfers. On 2/14/24 at 1:53 PM, Physical Therapy Assistant (PTA) I stated resident #197 was motivated on the first week of therapy because she wanted to go home. He explained that due to the fracture, the resident had pain and could not use her left arm so her therapy had to be extended. PTA I said resident #197 previously required moderate assistance for bed mobility but now required maximum to total assistance due to pain. He stated resident #197 told him there was only one person using the lift with her and she knew it was supposed to be two people. PTA I said, I also heard that it was one person using the mechanical lift with resident #197. Review of the written statement provided by the Administrator noted only one CNA was in the room when RN E was called to assist. The statement from RN E dated 2/8/24 at 6:00 PM, read, At the time of the incident CNA called me for help since she was using stand hoyer lift and she resident was in a unstable position and was kneeling towards the floor. She never crash to the ground. We had to put her on the floor for her safety. On 2/14/24 at 1:33 PM, the facility Administrator stated he came to the facility on 2/9/24 to interview staff after he was made aware of resident #197's x-ray results. He said resident #197 had been interviewed by the [NAME] Wing Unit Manager (UM) prior. The Administrator stated after his interviews, it was determined the root cause of the incident was resident #197 had become weak and a little dizzy during the transfer. He explained the two CNAs lowered her to the ground, then went to get the nurse. The Administrator stated resident #197 said she blacked out and could not recall the details. When asked if he had interviewed the resident, he said he had not interviewed the resident, but the UM did. When informed of the inconsistent statements from the two CNAs indicating whether RN E was present when the resident was placed on the floor from the lift, the Administrator did not provide an answer. On 2/15/24 at 12:15 PM, an interview was conducted with the Regional Nurse Consultant, the Director of Nursing (DON) and the Administrator. The Nurse Consultant explained that two person assist with transfers meant that two staff should be present to do the transfer. She described it could be for a standing lift or full mechanical lift transfers. She stated two person assist only indicated the number of staff, not the type of mechanical lift to be used. She acknowledged the type of mechanical lift was not reflected on resident #197's care plan until 2/08/24. The DON reported that CNAs would know the type of lift to be used with the resident as, It would be on the care plan and on the task. We manually add directions to the task. The Administrator added, in the morning meeting, the Minimum Data Set Nurse inputs any changes to the care plans and [NAME]. He explained after the meeting, any changes would be communicated to the CNAs verbally. He said the type of lift to be used for resident #197 should have been in the electronic system as a task but explained it did not get written in the [NAME] until 2/8/24. He did not clarify if the specific lift was added prior to the incident or after the incident. The Administrator reported the wrong mechanical lift was used for the resident as she did not like the full body mechanical lift and the CNA said she had used the sit to stand mechanical lift previously with the resident. When asked if CNAs determined the type of lift to use to transfer residents, the Administrator did not provide an answer. They were asked to clarify the inconsistencies in statements from the both the resident and RN E who stated only one CNA transferred the resident and CNAs G and F's statements that it was 2 CNAs. The Administrator replied he was told two CNAs transferred the resident. Review of CNA G's completed training included CNA Transfer/Lifting Competency Test completed one year ago, on 2/09/23. The facility policy, Safe Resident Handling/Transfers implemented 11/03/2020 and revised 11/29/22 read: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident. Two staff members must be utilized when transferring residents with a mechanical lift. Review of the CNA job description included duties to ambulate and transfer residents utilizing appropriate assistive devices and body mechanics. The resident sample was expanded to include five additional residents who were identified as requiring a mechanical lift for transfers. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 2-09-24, staff members involved were given 1:1 education by the Staff Development Coordinator on the proper use of mechanical lifts. * On 2-09-24 through 2-15-24 current nursing staff and therapy staff were educated on the transfer of residents and the use of the mechanical lifts by the Director of Nursing, Staff Development Coordinator and Nurse managers. Twenty five nursing staff members were educated on 2-09-24, 8 nursing staff members were educated on 2-12-24, 5 nursing staff were educated on 2-13-24, 1 nursing staff was educated on 2-14-24, 50 staff members were educated on 2-15-24. Newly hired staff members and agency staff will be educated during the orientation process. Staff members that are on vacation will receive education prior to the start of their next shift. * On 2-12-24 through 2-15-24 current staff were educated on ANME (Abuse, Neglect, Misappropriation, Exploitation) by Staff Development Coordinator, Nurse Managers and Department Heads. On 2-12-24, 18 facility staff members were educated, on 2-13-24, 17 facility staff members were educated, and on 2-15-24, 89 staff were educated. Newly hired staff members and agency staff will be educated during the orientation process. Staff members that are on vacation or FMLA will receive education prior to the start of their next shift. * On 2/16/24, out of 88 Total nursing and therapy employees-77 nursing and therapy employees received education on the use of the mechanical lifts. * On 2/16/24, out of 124 Total facility employees, 103 Facility staff received education on ANME. * Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held on 2-16-24 with Medical Director, Administrator, DON, Staff Development Coordinator, Therapy Director, and Unit Manager to discuss transfer status, mechanical lift use and root cause analysis. Interviews conducted from 2/17/24 with 13 facility staff including licensed nurses and CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan and [NAME] to identify number of persons and mode of transfer or which mechanical lift for resident transfers. They verified a return demonstration was completed after the education. They confirmed they received Abuse/Neglect education followed by a post test.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility neglected to implement policies and procedures and follow standards of practice related to care of a fracture with a brace for 1 of 6 residents reviewed for braces, (#1); and failed to provide the care and services to ensure the safety of a resident who was at risk for elopement for 1 of 6 residents reviewed for elopement, (#1), out of a total sample of 12 residents. These failures contributed to resident #1's hospitalization and elopement and placed him at risk for serious infection/injury/impairment/death. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On 8/22/22, resident #1 was admitted to the facility with a brace in place for a left wrist fracture. Facility staff did not obtain orders for necessary care and services, the device was never removed for skin evaluation, and the resident's left hand and arm were not assessed regularly. Resident #1 developed a wound and a skin infection under the brace and was transferred to the hospital on 9/10/22 for treatment. He required wound care, intravenous antibiotics, and consultation with an orthopedic specialist during his hospitalization. On 9/13/22, the resident was readmitted to the facility with a new splint. Nursing staff did not follow hospital discharge orders for follow up with the orthopedic specialist within two weeks. Over the next five months, resident #1's plan of care was not updated to reflect the frequency and duration of use of the device, and therapy orders were not obtained and implemented to promote optimal functional status. On 2/09/23 at approximately 1:00 PM, resident #1 left his room and walked towards the facility's front lobby unnoticed by staff. When the receptionist opened the front doors for incoming transportation personnel, she did not maintain focus on the doors and resident #1 left the building simultaneously. Nursing staff did not conduct rounds at the change of shift, and resident #1's assigned nurse did not notice he was missing until approximately 4:00 PM. On 2/12/23 at approximately 4:00 AM, a concerned citizen contacted law enforcement regarding the well-being of a man loitering at a gas station over three miles away from the facility. Law enforcement responded, identified the man as resident #1, and arranged medical transport to the hospital. The facility was unaware of resident #1's whereabouts for three days until law enforcement notified the Administrator he was found. The facility's failure to implement policies and procedures to prevent neglect and implement a plan of care that reflected necessary care and services placed all residents who had braces and/or were at risk for elopement at risk for serious infection/injury/impairment/death. This failure resulted in Immediate Jeopardy starting on 8/22/22. The Immediate Jeopardy was removed on 2/17/23. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F607, F684, F689, and F835. Review of the medical record revealed resident #1, a [AGE] year-old male, was admitted to the facility from the hospital on 8/22/22. His diagnoses included stroke, adult failure to thrive, alcohol abuse with alcohol-induced mood disorder, and altered mental status. The resident was readmitted to the facility on [DATE] and his demographic sheet was updated to reflect new diagnoses of left forearm fracture, local skin infection, and cellulitis of the left finger and left arm. On 2/14/23 at 5:02 PM, and 2/15/23 at 2:38 PM, in telephone interviews, resident #1's sister explained in August 2022 her brother was admitted to the facility from the hospital with a brace on his left arm for a wrist fracture. She said, When he was transferred to the facility there was a mix-up. They did not check the brace, change it, or take it off and he ended up with pressure sores under there. He needed antibiotics to treat that infection. They never took it off or cleaned it and he went back to the hospital for treatment. The resident's sister stated the facility notified her on the past Thursday, 2/09/23, that security cameras showed her brother left the facility unaccompanied at about 1:00 PM. She explained she was concerned about her brother's safety due to his impaired cognitive and physical status, and she was relieved when law enforcement found him. Resident #1's sister verified she was legally his healthcare surrogate. She explained her brother was an alcoholic who lived a transient lifestyle on the streets and been homeless for approximately ten years. The sister stated facility staff did not contact her when her brother was admitted or readmitted to obtain information about him. She said, Nobody asked me about previous behaviors or wandering. I think he would be at risk to leave the building because when he gets bothered about something, that's what he would do, get up and leave. Review of the medical record revealed there were no admission physician orders or care plans related to resident #1's fracture, brace, and no instructions to ensure nursing staff conducted thorough evaluations of his left arm to prevent complications from the device. On 2/15/23 at 11:07 AM, the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) were informed resident #1's medical record showed no admission orders in August 2022 related to his left wrist fracture or monitoring of his brace, and no evidence that a follow-up appointment was scheduled after re-admission from the hospital in September 2022. The DON stated she started work at the facility on 11/28/22 and was not aware resident #1 had a splint and suffered an injury as a result of appropriate care not being provided. She stated since the resident's elopement, she still had not reviewed his chart thoroughly. On 2/15/23 at 1:40 PM, the RNC stated she spoke with the Assistant DON and the previous DON who informed her resident #1 refused to have the brace removed for skin checks. The RNC acknowledged the resident's refusals should have been addressed with appropriate interventions. She confirmed the medical record contained no evidence alternate approaches were used to conduct skin evaluations and no instructions to nursing staff for monitoring his left hand. The RNC explained the admission nurse did not identify that resident #1 had a brace. She acknowledged the admission nurse, assigned nurses, and nursing management staff did not contact the hospital to clarify orders for the fracture and brace and/or notify the attending physician. The RNC confirmed the orthopedic consult was never arranged in the five months since readmission and resident #1's plan of care did not reflect instructions for use of the brace. She stated these issues were ultimately the responsibility of the nursing department. On 2/14/23 at 5:25, and 2/16/23 at 3:30 PM, the Director of Rehab confirmed resident #1 was admitted to the facility in August 2022 for therapy services. She recalled he was admitted with a left wrist fracture and ended up returning to the hospital three weeks later due to increased pain of the left arm and was readmitted on [DATE] and resumed therapy. She reviewed his chart and noted on initial admission and readmission, the resident was on Occupational Therapy caseload to work on tasks including dressing and activities of daily living. The Director of Rehab stated the therapist who did his initial evaluation in August 2022, Occupational Therapist (OT) E, noted the resident had a left wrist brace in place. The Director of Rehab stated the Nursing department would normally follow up to obtain orders for orthopedic consults and instructions for the brace. She acknowledged there was a lapse in communication and said, Therapists could have pushed a little more as they saw him five times weekly. The Director of Rehab stated she attended multiple interdisciplinary team (IDT) meetings including daily clinical meetings and did not recall any discussion regarding clarification of orders or revision of the plan of care for resident #1's fracture and brace. She validated every meeting over the past six months was a missed opportunity to exchange and discuss information and concerns about care and services for resident #1's left wrist fracture and brace. On 2/16/23 at 3:41 PM, OT E recalled resident #1 had a brace on admission and was readmitted from the hospital with a different type of removable device. She confirmed there were never any specific physician orders for therapy interventions such as passive range of motion exercises, but on readmission there was an order for follow up with an orthopedic specialist in one to two weeks. OT E reviewed resident #1's chart and confirmed he was last discharged from Occupational Therapy services on 10/12/22, approximately four weeks after readmission. When asked how she selected appropriate treatments for resident #1 despite no orders for either admission, OT E said, I kept doing what was done in the hospital. During the time he was on caseload, I recall asking nursing staff at least once a week at a minimum regarding [orthopedic] follow up. I spoke directly to the DON, possibly twice, and she stated she would follow up. OT E explained she received a physician's order today and evaluated resident #1's left wrist for the first time. She stated his pain level with left wrist movement was eight on a zero to ten scale. OT E confirmed the resident was left-hand dominant and now compensated by doing activities of daily living (ADLs) including eating with right non-dominant hand. Review of the admission Elopement Evaluation dated 8/22/23 revealed an elopement risk score of NA or not applicable. The document indicated scores of ten or above deemed a resident to be at risk for elopement. The evaluation incorrectly showed resident #1 was dependent for ADLs or could not move without assistance. Questions related to the resident's mental status, mobility, speech patterns, history of wandering, and contributing diagnoses including cognitive impairment were left blank. There was no associated nursing documentation to show the admission nurse or any member of nursing management contacted the resident's sister, his healthcare surrogate, to obtain accurate information regarding his medical and social history. On 2/16/23 at 10:49 AM, the RNC explained the score of NA on admission elopement evaluation resulted from the admission nurse's selection that inaccurately deemed resident #1 dependent for ADLs or not able to move independently. She acknowledged that response conflicted with information on the hospital transfer form. The RNC validated there was no evidence in the medical record that resident #1's healthcare surrogate was contacted to ensure admission evaluation form were completed correctly. On 2/14/23 at 5:44 PM, the Administrator, DON and RNC discussed the facility's elopement incident investigation. The Administrator explained resident #1 walked through the front lobby doors unnoticed by staff when the receptionist unlocked and opened the doors for transportation personnel who arrived to pick up another resident. He confirmed the receptionist was not able to see the door from her desk, and she did not look at the security camera monitors to ensure there was no unauthorized egress from the facility. The DON explained nursing staff did not notice the resident was missing until after 4:00 PM as none of the assigned staff conducted walking rounds at change of shift. The DON stated the investigation showed Certified Nursing Assistant (CNA) B who was assigned to the resident during the 7:00 AM to 3:00 PM shift was on break after the residents' lunch meals were completed. The DON discovered at change of shift, CNA C, who was assigned to the resident on the 3:00 PM to 11:00 PM felt rounding was unnecessary as she had worked on the opposite hallway and saw CNA B's residents periodically throughout the day shift. The Administrator stated on Sunday 2/12/23 at 4:32 AM, three days after the resident walked out of the facility, a police officer called to notify him resident #1 was at a gas station in another city. The Administrator recalled the police officer described resident #1 as looking cold and hungry when he was found. The Administrator stated resident #1 had no injuries but complained of mild back pain so he was transported from that location to the hospital for evaluation. On 2/16/22 at 12:09 AM, in a telephone interview, the convenience store employee explained he called the police when he became concerned about a man who had been outside the location at night for two to three days. He said, Something was off about him. I did not see where he slept but I assume he slept at the tables. The employee stated one of the regular homeless people who spent the nights outside the convenience store brought concerns about the man's condition to his attention. The regular homeless person told the convenience store employee the man seemed to be defecating on the benches and said, This new guy has been all over my corner. He made a mess of it. The convenience store employee stated the regular homeless person told him customers had bought food for him but he barely touched it. The convenience store employee said, He seemed like a wounded animal, just laying there in his own filth and refusing to eat anything. On 2/15/23 at 11:07 AM, the DON stated when resident #1 returned to the facility, she assessed him and noted his feet were macerated and he had blisters on both feet. She recalled it had been raining for several days and confirmed it was probable the resident's feet had been wet for an extended period of time. The DON stated resident #1 was currently being seen by a Wound Care specialist physician. On 2/15/23 at 12:41 PM, the Wound Care physician reviewed his notes and stated he assessed and treated resident #1 after he was hospitalized for a left hand wound and cellulitis. He explained it was a professional standard of practice for nursing staff to conduct regular checks of all areas under any device to ensure no skin breakdown such as pressure or friction occurred. He stated complications could be avoided if nursing staff monitored an extremity with a brace for signs of swelling, redness, and compromised circulation every shift. The Wound Care physician emphasized it was essential to promptly report any issues to the attending physician. He stated he was in the facility today to evaluate and treat blisters on resident #1's feet. The Wound Care physician was aware the resident was missing for three days, and the total distance he walked was unknown. He explained the blisters were probably a result of friction from his shoes. Review of a Wound Care Consult note dated 2/15/23 revealed resident #1 had lesions to both feet. The document indicated blisters on the right foot measured 2.0 centimeters (cm) x 2.0 cm, and 3.0 cm x 3.0 cm. The blisters on the left foot measured 2.5 cm x 1.5 cm, and 0.6 cm x 0.7 cm. The Wound Care physician noted the etiology of all lesions was trauma and friction. On 2/17/23 at 9:43 AM, CNA G stated she was assigned to care for resident #1 when he was returned to the facility. She recalled he wore the same clothing he was last seen in three days before and said, He was very dirty. His hair was long and all over the place. He had a full beard, and it was dirty. He smelled like urine. It was strong.He had blisters on both feet, bubbled skin. CNA G stated resident #1 was unsteady and weak when she transferred him to a wheelchair. On 2/17/23 at 4:06 PM, the DON explained professional nursing standards would guide nurses to note the resident's brace, identify potential issues, contact the attending physician for orders, and if no records were included in admission paperwork, contact the hospital. The DON stated her expectation was nurses would communicate with authorized representatives if residents were unable to provide reliable information. She acknowledged the IDT was responsible for reviewing the medical records of newly admitted , readmitted , and current residents to ensure the completion and accuracy of documentation including admission assessments and elopement evaluations. The DON validated although there was interdepartmental communication and IDT meetings, somehow resident #1's splint went unnoticed and untreated, and his risk for elopement was never identified. She confirmed information regarding necessary care and services to meet his needs was not entered into his plan of care. Review of the job description for Registered Nurse dated April 2020 revealed essential duties included consult with the resident's physician in providing the resident's care, treatment [and] rehabilitation. Registered Nurses were expected to review residents' care plans daily to verify they received appropriate care and services. Review of the job description for Licensed Practical Nurse dated July 2021 revealed essential duties included working with physicians to review treatment plans and making rounds to ensure that care and services were being provided appropriately, and also to evaluate resident status. The facility's policy and procedure for Abuse, Neglect and Exploitation revised 7/13/22, defined Neglect as .failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/05/22, resident #1's wound was noted to be healed by the Wound Care physician. *On 2/09/23 at 4:09 PM, a complete headcount by nursing staff confirmed all residents of facility were present, except resident #1. *On 2/09/23, the nursing management team completed elopement risk evaluations on all residents and no new residents were identified as at risk. The elopement risk binders were reviewed by the DON to validate that each resident at risk for elopement had demographic information in the binder. *On 2/09/23, the DON reviewed clinical records of residents identified to be at risk for elopement to confirm elopement risk care plans were in place. Residents were confirmed to have orders in place for increased monitoring, behavior monitoring for exit seeking, interventions attempted for exit seeking and outcome of those interventions. *On 2/09/23, the Staff Development Coordinator (SDC) initiated all staff education on the facility's policy for prevention of Abuse, Neglect and Exploitation, with an emphasis on Neglect, to include reporting requirements, elopement standard and guidelines, responding to door alarms and proper actions to take upon responding, and maintaining visual observation of all persons entering and exiting the facility. A post-test was used to validate comprehension of education received. The facility achieved 100% compliance on 2/16/23. *On 2/09/23, the button that allowed staff to open the front lobby doors remotely, without direct supervision of the doors, was removed by the Maintenance Director. The front desk staff were educated by the Administrator on only opening the front lobby doors at the keypad next to door. *On 2/09/23, the Maintenance Director relocated the receptionist's desk to an area that allows direct supervision of the door. *On 2/10/23, the facility held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting. Attendees included the Medical Director. The committee reviewed QAPI minutes and accepted the Performance Improvement Plan. *On 2/10/23 at 5:30 AM, the Maintenance Director checked egress doors for alarms and function with no issues identified. *On 2/10/23, the Receptionist job description was revised by the Administrator to include maintaining visual observation of persons entering and exiting the front door. *On 2/10/23, elopement drills were initiated on the 11:00 PM to 7:00 AM shift and conducted every shift until the 11:00 PM to 7:00 AM on 2/16/23. Elopement drills will be ongoing, conducted weekly on alternating shifts until it is determined by the QAPI committee that it is appropriate to decrease the frequency to monthly on alternating shifts. *On 2/12/23, resident #1 was found by law enforcement, transported to the hospital for evaluation, and returned to the care of the facility at approximately 11:20 AM. The DON completed a head-to-toe assessment of resident #1 and noted blisters to both feet and scabbed areas to his right hand and right arm. *On 2/12/23, resident #1 was assessed for elopement risk and identified as high risk. His photo and demographic information were placed in the Elopement Risk Binder. The resident was placed on one-to-one supervision immediately and will remain with that level of supervision until otherwise determined by the interdisciplinary team. *On 2/12/23, the RNC and members of the facility's management team reviewed and revised the facility's Elopement Evaluation form to include additional risk factors of history of homelessness and substance abuse. All current residents were re-evaluated for elopement risk by the nursing administrative team and one new resident was identified as at risk. *On 2/14/23, Elopement Binder Quality Monitoring (QM) reviews were completed. A Quality Review re: elopement process was completed. * On 2/15/2023, the Restorative nurse was educated on care plans, tasks, and management of splints to ensure the provision of care. *On 2/16/23, resident #1 had an x-ray that showed a healed distal radial fracture. *On 2/16/23, the clinical management team completed skin assessments of 100% of current residents and no new skin alterations were identified. *On 2/16/23, active nursing staff were educated on completion of weekly skin observations, documentation, and notification. The facility achieved 94% compliance. The facility utilized a scenario of Neglect related to not providing appropriate clinical care and identification of Neglect. Any nurse that has not received the education will be educated prior to next scheduled shift. *On 2/16/23, a Splint binder was created. Current splints have a task assigned in the plan of care that includes skin integrity check before and after placement. *On 2/16/23, current new admissions/re-admission charts were reviewed for appointments. Any concerns identified were corrected at this time. A review of follow up appointments for future appointments revealed no concerns. *On 2/16/23, Nurse Managers were educated on reviewing new admissions/re-admissions and follow up appointments for new orders. They were educated on the creation of a transportation binder that is communicated daily in morning clinical meetings and updated with transportation pick up time, location of appointment, escort, and then follow up information from the appointment. (i.e., new orders, future appointments, referrals etc.) *On 2/16/23, the facility achieved 100% with education provided by the SDC for nursing staff on rounding during and between shifts. Agency staff and newly hired staff will be educated during the orientation process or prior to starting their next shift. *On 2/17/23, an Ad Hoc QAPI committee meeting was completed with the Medical Director to review current QAPI Performance Improvement Plans to determine the need for further changes. Results of elopement drills were reviewed by the QAPI committee to determine any need for systematic change. All plans were agreed upon and accepted. Review of in-service attendance records revealed staff signatures to reflect participation in education on topics listed above. On 2/17/23, interviews were conducted with five Registered Nurses, four Licensed Practical Nurses, nine CNAs, one Occupational Therapist, the Activity Director, and one laundry staff. All verbalized understanding of the education provided. The resident sample was expanded to include five additional residents who wore braces and five additional residents who were at risk for elopement. Observations, interviews, and record reviews revealed no concerns for residents, #2, #3, #4, #5, #6, #7, #9, #10, #11, and #12 related to the provision of necessary care and services to prevent Neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain physician orders and implement nursing interventions to promote healing of a fracture and prevent skin injury related to use of a brace; and failed to arrange a required orthopedic consultation and update the plan of care with approaches for management of a brace for 1 of 6 residents reviewed for braces of a total sample of 12 residents, (#1). These failures contributed to resident #1's hospitalization and placed him at risk for decreased mobility and serious infection/injury/impairment/death. On 8/22/22, resident #1 was admitted to the facility with a brace in place for a left wrist fracture. Facility staff did not obtain orders for necessary care and services, the device was never removed for skin evaluation, and the resident's left hand and arm were not assessed regularly. Resident #1 developed a wound and a skin infection under the brace and was transferred to the hospital on 9/10/22 for treatment. He required wound care, intravenous antibiotics, and consultation with an orthopedic specialist during his hospitalization. On 9/13/22, the resident was readmitted to the facility with a new brace. Nursing staff did not follow hospital discharge orders for follow up with the orthopedic specialist within two weeks. Over the next five months, resident #1's plan of care was not updated to reflect the frequency and duration of use of the device, and therapy orders were not obtained and implemented to promote optimal functional status. The facility's failure to provide appropriate care and services for a resident with a brace, and failure to obtain a follow up orthopedic appointment placed all residents with fractures and/or braces at risk for alteration in healing, decreased mobility, development of preventable wounds and infections, and at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy which began on 8/22/22 and was removed on 2/17/23. Findings: Cross reference F600, F607, and F835. Review of the medical record revealed resident #1, a [AGE] year-old male, was admitted to the facility from the hospital on 8/22/22. His diagnoses included stroke, adult failure to thrive, alcohol abuse with alcohol-induced mood disorder, and altered mental status. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 8/22/22 revealed resident #1's primary diagnosis in the hospital was altered mental status. The document indicated he required a surrogate to make healthcare decisions and was alert and disoriented but could follow simple instructions. The form revealed resident #1's rehabilitation potential was fair, and he was to be evaluated and treated by Physical Therapy five times weekly. On 2/14/23 at 5:02 PM, in a telephone interview, resident #1's sister explained in August 2022 her brother was admitted to the facility from the hospital with a brace on his left arm for a wrist fracture. She said, When he was transferred to the facility there was a mix-up. They did not check the brace, change it, or take it off and he ended up with pressure sores under there. He needed antibiotics to treat that infection. They never took it off or cleaned it and he went back to the hospital for treatment. Review of the admission nurse's Skilled Evaluation dated 8/22/22 revealed resident #1's skin was warm and dry, and he was able to move all extremities. The evaluation showed he had no impairment of the upper extremity (shoulder, elbow, wrist, hand). The section of the document designated for details of notifications made to the provider and responsible party was left blank, and there was no narrative note regarding any additional findings such as a left hand brace or of attempts to obtain information from the hospital or representative. The Minimum Data Set (MDS) Version 1.17.1 admission assessment with assessment reference date of 8/26/22 revealed resident #1 displayed no behavioral symptoms and did not reject evaluation or care .that is necessary to achieve the resident's goals for health and well-being. The document showed he had no impairment of his upper extremity, received Physical and Occupational Therapy services, and did not have restorative nursing services that included brace or brace assistance. The MDS assessment revealed staff were unable to determine if the resident had a fracture related to a fall in the previous six months. Resident #1's Occupational Therapy evaluation dated 8/23/22 revealed documentation of a left wrist brace in place for an unknown injury. Occupational Therapist (OT) E noted the hospital record did not provide information on the injury and resident #1 was unable to offer clarification. She was unable to test the strength of his left arm due to presence of the brace. The OT plan of treatment recommended light right arm exercises as tolerated. Review of Occupational Therapy Treatment Encounter Notes from 8/23/22 to 9/09/22 revealed no documentation of additional information or clarification regarding resident #1's unknown injury or plan of care related to his left arm. On 8/30/22, OT E noted resident #1 complained of left arm pain while applying slight pressure on the walker. She collaborated with physical therapy staff regarding trial of an alternate device but there was no evidence OT E communicated with the resident's assigned nurse about his left arm pain and the brace. An Occupational Therapy Discharge Summary dated 9/12/22 revealed resident #1 had progressed with rehab services but was discharged to the hospital for evaluation of his left wrist which remained in a device for an unknown purpose. Review of the medical record revealed there were no admission physician orders or care plans related to resident #1's fracture, brace, and no instructions to ensure nursing staff conducted thorough evaluations of his left arm to prevent complications from the device. The facility's policy and procedure admission Orders revised on 1/06/23 revealed the facility would obtain written or verbal physician or practitioner orders for residents' immediate care needs. The document read, The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission. The orders should provide information to maintain or improve the resident's functional abilities. The facility's Pressure Injury Prevention Guidelines revised on 1/06/23, individualized preventative interventions in accordance with physician orders. In the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders. A Medical Professional Progress Note dated 8/24/22 revealed Advanced Practice Registered Nurse (APRN) F assessed resident #1 and wrote, Extremities normal, no edema. APRN F's note did not reflect the presence of a left arm brace or a request for additional information about the injury or the device, and her plan of care did not include orders for monitoring the resident's arm and brace to prevent complications. A Late Entry Medical Professional Progress Note dated 8/25/22 revealed the attending physician assessed resident #1 and wrote, It was found he had a left forearm fracture due to a trauma. The note read, Plan of care discussed with nursing staff. However, the document did not include findings or orders related to a treatment plan of the resident's fracture and use of the brace. Another Late Entry progress note by the attending physician was dated 9/01/22 and indicated resident #1 had color changes and pain to his left arm. The note read, X ray was ordered and a fracture was discovered. [Patient]will probably be sent to the hospital. However, review of the medical record revealed inconsistency with the date of the attending physician's note. A Radiology Report indicated the x-ray of resident #1's left forearm that showed a fracture was done on 9/10/22, nine days after the Late Entry note. On 2/16/23 at 11:08 AM, in a telephone interview, APRN F recalled resident #1 was admitted to the facility with the brace, and no record of orthopedic orders. She explained resident #1 was not a good historian and could not provide information. APRN F recalled on the day she conducted her initial assessment, nursing staff were checking for the orders related to the brace. APRN F acknowledged she did not document the device on her initial assessment note, nor give orders and recommendations for monitoring and treatment. APRN F said, I would think the nurse would have mentioned a device to the admitting physician, especially if there are no orders from the hospital. I would expect the nurse to follow up with the hospital and possibly request an [orthopedic] consult if no orders were found. Resident #1's medical record revealed a physician order dated 8/23/22 for weekly skin evaluations every Monday during the evening shift. Review of Progress Notes revealed resident #1 had a complete nursing skin assessment on 8/24/22 that showed Overall skin intact. The nurse's note did not indicate there was a brace on his left arm. A Weekly Skin Evaluation with an effective date of Monday 8/29/22 but signed a week later on 9/05/22 read, Resident refused skin evaluation. Areas that were seen included discoloration to bilateral upper extremities. There was a brace on left lower arm. In a Late Entry Narrative Note dated 9/08/22, the Assistant Director of Nursing (ADON) noted she spoke with resident #1 and his sister about the left arm brace and then updated the physician who ordered an x-ray based on her concerns. The ADON did not document the condition of the resident's brace or skin, or any alternative approaches used to conduct a thorough skin assessment. On 2/15/23 at 2:10 PM, the ADON stated she had never been assigned to care for resident #1, and she could not remember why she assessed his left hand. She said, I'm assuming it was because someone said something about a brace.I remember that he would not allow me to see it. I would assume a nurse or [Certified Nursing Assistant] CNA noticed something wrong. She acknowledged her nursing note was a Late Entry note and did not describe her assessment findings. Resident #1's medical record revealed a SBAR [Situation, Background, Appearance, Review and Notify] Communication Form dated 9/10/22. The form indicated the resident had swelling, pain and an abrasion to his left thumb and forearm. A SNF/NF [Skilled Nursing Facility / Nursing Facility] Transfer Form dated 9/10/22 at 10:45 PM, revealed resident #1 had a pressure ulcer or injury associated with a brace on his left forearm. The document indicated he was noncompliant with activities of daily living (ADL) care and his left forearm was not assessed. Review of the hospital record from 9/10/22 to 9/13/22 revealed resident #1 arrived in the Emergency Department on 9/10/22 at 11:35 PM, for treatment of a thumb wound caused by a Velcro wrist strap on an orthotic device that became embedded in his thumb after not being removed for over ten days. His left hand was extremely swollen, and he had limited range of motion of his fingers. The hospital record described the wound as a medical device related pressure injury that was painful, bleeding, draining, with a foul, pungent odor. Diagnostic testing done on 9/11/22 revealed resident #1 had a healing wrist fracture, a foul-smelling wound, and evidence of cellulitis or a skin infection. Resident #1 was assessed by an Infectious Disease specialist physician who ordered two intravenous (IV) antibiotics, Cefepime 2 grams and Vancomycin 1500 milligrams (mg) to treat his left hand tendon infection. The hospital Discharge Summary dated 9/13/22 revealed the orthopedic specialist physician .evaluated patient and placed Velcro wrist brace with padding underneath, follow-up in 1-2 weeks as an outpatient. Wound care recommended to be continued. The document included instructions to follow up with specialists as directed. Resident #1 was readmitted to the facility on [DATE] and his demographic sheet was updated to reflect new diagnoses of left forearm fracture, local skin infection, and cellulitis of the left finger and left arm. The Order Summary Report showed on readmission, resident #1 had a wound treatment order dated 9/14/22 to cleanse the wound at the base of his left thumb with normal saline and apply calcium alginate to absorb drainage daily and as needed. The resident also had medication orders dated 9/14/22 for oral antibiotic medications for cellulitis, Doxycycline Hyclate 100 mg twice daily for seven days and Levaquin 500 mg once daily until 9/19/22. The report reflected orders dated 9/14/22 for a Wound Care specialist physician consult and follow-up with an Orthopedic specialist physician in one to two weeks. An order dated 9/14/22 read, Monitor capillary refill for nail beds to left hand. May remove brace for skin assessment. A Wound Care Consult note dated 9/14/22 revealed resident #1 was seen post-hospitalization for left hand swelling, drainage, and abscess. The assessment described a wound at the base of the resident's left thumb with etiologies of abscess [and] surgical that measured 0.4 x 3.0 x 0.3 centimeters (cm). The Wound Care physician noted resident #1 wore the left forearm brace. On 2/15/23 at 12:41 PM, the Wound Care specialist physician confirmed he was consulted to assess and treat resident #1 after he was hospitalized for left arm cellulitis and a left thumb wound in September 2022. He reviewed his notes and stated the resident wore a left forearm brace during his initial evaluation on 9/14/22. He explained it was a professional standard of practice for clinical staff to conduct regular skin checks of all areas under any removable device regularly to ensure there was no skin breakdown caused by pressure or friction. The Wound Care physician stated nursing staff should check any extremity with a device for swelling, redness, skin condition, and evidence of compromised circulation every shift. He stated he would expect nurses to promptly report any issues observed on an extremity with a device. The medical record did not contain progress notes or orders related to an orthopedic consultant follow-up after readmission. In addition, there was no documentation regarding protocols for donning and doffing the brace, duration of use, and specific therapeutic exercises to promote healing of the fracture and improve the resident's mobility. Review of the policy and procedure Skin Assessment revised on 1/06/23 revealed performance of a full body assessment was an integral approach to preventing pressure injuries. The document indicated the assessment would be conducted on admission, readmission and then weekly. The procedure directed nurses to remove any devices if not ordered to remain in place. Review of resident #1's skin evaluations from September 2022 to February 2023 revealed his brace was in place from 9/14/22 to 10/20/22. From 10/27/22 to 2/08/23, Weekly Skin Evaluation forms did not reflect use of a brace. The skin checks were not done as ordered over this period, with six of eighteen evaluations missed. The medical record did not indicate when, if, why, or by whom resident #1's brace was discontinued. Although the Medication Administration Record for February 2023 showed nurses' initials to validate resident #1's left hand was checked every shift, there was no documentation to show whether or not he still wore the brace. On 2/14/23 at 4:32 PM, resident #1 was observed in bed with no brace on his left arm. On 2/15/23 at 10:26 AM, he still did not wear a brace and a blue device was noted on the bedside table, partially covered by a backpack. On 2/15/23 at 4:40 PM, the facility's Appointment Scheduler stated she had never been asked to make an outside physician appointment or arrange transport for resident #1. She provided her log and reviewed all residents' appointments made from August 2022 to February 2023. The log showed no documentation of an appointment for an outpatient orthopedic consultation. On 2/15/23 at 1:40 PM, 2/15/23 at 4:46 PM and 2/16/23 at 1:07 PM, the Regional Nurse Consultant (RNC) stated she reviewed resident #1's chart and saw no evidence that his follow-up orthopedic consult was ever arranged. She explained if resident #1 required brace application, he should either have been on the facility's Restorative Nursing Program or had the task added to the Treatment Administration Record. The RNC confirmed resident #1's medical record did not show adequate instructions and appropriate orders for care of his left arm fracture and brace. The RNC acknowledged staff did not evaluate and monitor resident #1's left hand according to facility protocols. She explained on admission and readmission, nurses were to conduct a full assessment and identify and document that a brace was in place. The RNC stated if there were no orders for follow up of a fracture and monitoring the extremity with a brace, her expectation was nurses would contact the hospital and mention the brace to the attending physician at the time other admission orders were obtained. The RNC verified clarification of resident #1's orders related to his fracture and brace was ultimately the responsibility of the nursing department. On 2/15/23 at 10:33 AM, and 2/16/23 at 3:41 PM, OT E stated on his initial admission assessment, resident #1 had a brace. She recalled the hospital record did not indicate he had a left wrist injury. OT E said, I probably discussed with his assigned nurse on that hall. It was my understanding that nursing would follow up. She stated resident #1 was hospitalized for issues related to his brace and readmitted with another device. She explained there were no therapy readmission orders such as passive range of motion for his left hand. OT E said, We were waiting for guidance. I do know about the follow-up being ordered. I read it in the hospital notes when he came back. OT E confirmed resident #1 was on therapy caseload from 9/15/22 to 10/12/22, and during the four week period no clarification was received regarding treatment for the resident's fracture and use of the brace. OT E explained she was directed to evaluate the resident today and found he had a pain level of eight on a zero to ten scale with movement of his left wrist. She stated the resident had limited range of motion of the left wrist which currently impacted him as it was his dominant hand. OT E stated resident #1 now compensated by using his right hand for eating and other ADLs. On 2/17/23 at 1:30 PM, the Director of Rehab stated the normal process for residents admitted with fractures involved a follow-up with the treating orthopedic physician. She explained most orthopedic specialists were very particular about their orders, such as range of motion exercises with specified measurements in degrees and maximum weight limits. The Director of Rehab stated those types of restrictions were necessary to promote the healing process. She acknowledged that if a resident did not receive appropriate rehab services, negative outcomes could include decreased range of motion, weakness, stiffness, pain, and difficulty with tasks that required fine motor movement. Review of the facility's policy and procedure for Restorative Nursing Programs revised on 1/06/23, revealed the facility would provide services to maintain or improve a resident's abilities, to include assistance with braces and passive or active range of motion exercises. Review of the Facility Assessment dated 3/10/22 revealed the facility could provide care for residents with musculoskeletal conditions including fractures. Services included assistance with ADLs, wound care, and rehabilitation. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/05/22, resident #1's wound was noted to be healed by the Wound Care physician. *On 2/15/23, the physician's order to monitor capillary refill for the resident's nail beds to left hand was discontinued. *On 2/15/23, the Restorative Nurse received education related to care plans, tasks and management of splints. *On 2/16/23, resident #1 had an x-ray that showed a healed distal radial fracture. *On 2/16/23, the clinical management team completed skin assessments of 100% of current residents and no new skin alterations were identified. *On 2/16/23, the Restorative Nurse completed an audit of the facility's restorative splint programs. Any required corrections were made at that time. *On 2/16/23, the facility achieved 94% compliance with education provided to active nursing staff related to the completion of weekly skin observations, documentation, and notification. Any nurse who has not received the education will be educated prior to the next scheduled shift. *On 2/16/23, a splint binder was created, and residents who currently use splints have a task assigned in the plan of care that includes skin integrity check before and after placement. *On 2/16/23, current new admissions/re-admission charts were reviewed for appointments. Any concerns identified were corrected at this time. Follow up appointments for future appointments were reviewed with no concerns noted. *On 2/16/23, education was provided for Nurse Managers regarding reviewing new admissions/re-admissions and follow up appointments for new orders. Education included creation of a transportation binder that is communicated daily in morning clinical meetings and updated with transportation pick up time, location of appointment, escort, and then follow up information from the appointment. (i.e., new orders, future appointments, referrals etc.) *On 2/17/23, the facility held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting with the Medical Director in attendance. All plans were agreed upon and accepted. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on topics listed above. On 2/17/23, interviews were conducted with four Registered Nurses, four Licensed Practical Nurses, and one Occupational Therapist. All verbalized understanding of the education provided. The resident sample was expanded to include five additional residents who wore braces. Observations, interviews, and record reviews revealed no concerns for residents #7, #9, #10, #11, and #12 related to obtaining and following physician orders, and developing and implementing appropriate nursing interventions for braces.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring for a physically and cognitively impaired vulnerable resident to prevent unsupervised exit from the facility through the front lobby doors for 1 of 6 residents reviewed for elopement, out of a total sample of 12 residents, (#1). This failure contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On 2/09/23 at approximately 1:00 PM, resident #1 left his room and walked towards the facility's front lobby unnoticed by staff. When the receptionist opened the front doors for incoming transportation personnel, she did not maintain focus on the doors and resident #1 left the building simultaneously. Nursing staff did not conduct rounds at the change of shift, and resident #1's assigned nurse did not notice he was missing until approximately 4:00 PM. On 2/12/23 at approximately 4:00 AM, a concerned citizen contacted law enforcement regarding the well-being of a man loitering at a gas station over three miles away from the facility. Law enforcement responded, identified the man as resident #1, and arranged medical transport to the hospital. The facility was unaware of resident #1's whereabouts for three days until law enforcement notified the Administrator he was found. The facility's failure to accurately identify elopement risk factors, provide the appropriate level of supervision, and maintain a secure environment contributed to resident #1's elopement and placed all residents who wandered at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy which began on 2/09/23 and was removed on 2/17/23. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F600 and F835. Review of the medical record revealed resident #1, a [AGE] year-old male, was admitted to the facility from the hospital on 8/22/22. His diagnoses included stroke, adult failure to thrive, hypertension, major depressive disorder, homelessness, alcohol abuse with alcohol-induced mood disorder, altered mental status, and metabolic encephalopathy. Metabolic encephalopathy is defined as a syndrome of temporary or permanent disturbance of brain functions that occurs in different diseases. Resulting psychiatric and neurological symptoms range from mild mental disorders to coma and death (retrieved on 2/22/23 from https://pubmed.ncbi.nlm.nih.gov/28084256/). The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 8/22/22 revealed resident #1's primary diagnosis in the hospital was altered mental status. The document indicated he required a surrogate to make healthcare decisions and was alert and disoriented but could follow simple instructions. The form revealed he had risk alerts for falls, difficulty swallowing, and seizures. Resident #1 walked and transferred with assistance, was fully weight-bearing, and used a walker. Review of the admission nurse's Skilled Evaluation dated 8/22/22 revealed on page one that resident #1's clinical evaluation showed he was not alert and oriented, did not have clear speech, and he exhibited comprehension issues. However, in conflicting information on page two, the admission nurse noted the resident was alert and oriented to person, place, and time with no cognitive impairment. The evaluation did not reflect safety precautions for seizures as noted on the hospital transfer form. The resident's gait was documented as unsteady with poor balance, but he was able to reposition himself and move all extremities. The evaluation form indicated resident #1 did not wander at night, but the source of that information was not evident as there was no documentation of contact with his healthcare surrogate. Review of the admission Elopement Evaluation dated 8/22/23 revealed an elopement risk score of NA or not applicable. The document indicated scores of ten or above deemed a resident to be at risk for elopement. The evaluation incorrectly showed resident #1 was dependent for activities of daily living (ADLs) or could not move without assistance. Questions related to the resident's mental status, mobility, speech patterns, history of wandering, and contributing diagnoses including cognitive impairment were left blank. Review of resident #1's medical record revealed the facility did not initiate a care plan for elopement risk on admission. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 9/13/22 revealed resident #1 was hospitalized for treatment of left hand cellulitis and a healing fracture. The form indicated he was at risk for falls, independently ambulatory, did not require a mobility device, and remained alert and disoriented. Review of hospital Discharge Summary Case Management discharge planning documentation in the hospital record revealed the resident .would like to return to rehab but not the rehab he was previously at. However, the hospital transfer form indicated resident #1 returned to the facility. Review of the readmission Elopement Evaluation dated 9/13/22 revealed resident #1's elopement risk score was four, which deemed him not to be at risk for elopement. The evaluation incorrectly showed he had no diagnosis of dementia or cognitive impairment and noted no history of wandering. The Quarterly Minimum Data Set (MDS), Version 1.17.1 assessment with assessment reference date of 11/26/22 revealed resident #1 had a Brief Interview for Mental Status score of 10 out of 15 which indicated moderate cognitive impairment. The MDS assessment indicated the resident was independent for transfers, walking, and eating. He required limited assistance with bed mobility, extensive assistance for toilet use and personal hygiene, and physical help with bathing. The resident's balance was unsteady, but he was able to stabilize himself without staff assistance. The document revealed he was frequently incontinent of urine, and experienced shortness of breath when lying flat. Resident #1's family did not participate the assessment. Review of the readmission Elopement Evaluation dated 12/13/22 revealed resident #1's elopement risk score remained four, and still showed he had no diagnosis of dementia or cognitive impairment. A Late Entry nursing Narrative Note dated 2/09/23 at 4:10 PM revealed resident #1's nurse noted he was not in his room during rounds and a search was initiated. Staff were unable to find him, and notifications were made to the physician, family, State agency, and law enforcement. On 2/14/23 at 4:32 PM, resident #1 was in his room with Certified Nursing Assistant (CNA) G seated at the doorway. CNA G explained she was assigned to provide one-on-one supervision for resident #1 as he had recently eloped. Resident #1 was alert to self only and was not able to name his current city of residence. He verified he recently left the facility, and when asked why, the resident said, I was just looking for something better. Resident #1 explained he had memory issues and could not recall details of his time outside the facility but thought he slept somewhere like a [name of a large 24-hour gas station / convenience store]. On 2/14/23 at 5:02 PM, in a telephone interview, resident #1's sister stated her brother had lived a transient lifestyle on the streets and been homeless for approximately ten years. She explained he was an alcoholic and his condition had worsened in the last two years. The sister stated in the past, he would normally go to a relative's home or to a homeless shelter when he needed a place to sleep or needed food, but recently he rarely did this due to his mental decline. She stated he also began to have significant balance issues that resulted in several falls from his bicycle. The resident's sister stated he usually stayed in his room and was a loner who did not like confrontation. She recalled on the past Thursday, the facility called her at about 4:00 PM to ask if she or anyone else had taken her brother out of the building. She stated the facility called again at about 4:45 PM to inform her the security cameras showed her brother got out of the facility at about 1:00 PM, and they had notified law enforcement. Resident #1's sister stated her brother did not have a cell phone, credit cards, or cash, and the weather forecast indicated rain and cool temperatures. She explained law enforcement did not find her brother on Thursday or Friday, so after work on Friday and again during the day on Saturday she drove around searching for him unsuccessfully. She said, I would think there were dangers out there for him although he does have some street smarts. We thought we were going to get a call that he froze to death. Resident #1's sister recalled on Sunday morning at about 7:30 AM, the facility notified her that her brother had been found at a gas station in another city. On 2/15/23 at 10:41 AM, the receptionist stated her desk was located in the mail room on the right side of the lobby, and there was a frosted sliding glass window that faced the opposite wall. She explained the front lobby doors were to the left of her office, but she could not see them when seated at her desk. She stated there was a monitor on her desk that showed different views of the lobby area and she used buttons under the desk to remotely unlock and open front doors. The receptionist recalled on the day resident #1 eloped, she was standing in the doorway of her office shortly after 1:00 PM, when she saw resident #8's transportation personnel approaching the front doors. The receptionist said, I took my eyes off the door when I leaned in to push the button. She stated she neither saw resident #1 in the lobby area, nor noticed him leave through the doors. The receptionist stated she was not aware resident #1 was gone until someone called her at about 4:00 PM during her break. On 2/15/23 at 12:51 PM, videotape recording from the security camera system was reviewed with the Administrator. The footage showed the events occurred on 2/09/23. At 1:05 PM, resident #8 was seated in her wheelchair in the lobby facing the front doors, awaiting transportation personnel for an appointment. At 1:09 PM, the footage showed transportation personnel rang the doorbell as resident #1 was observed walking through the lobby. The resident was approximately eight feet from the front doors when the bell rang. At 1:09 PM, as the double doors swung open to allow the transportation personnel to enter, resident #1 simultaneously exited and left the building. The resident followed the walkway and was quickly out of camera range. Review of a law enforcement Event Report dated 2/12/23 at 4:09 AM, revealed officers were dispatched to a large gas station and convenience store in response to an employee's call about a man in dirty clothing who was seated on the sidewalk and appears to look like he hasn't eaten in days. The document indicated officers arrived at the location at 4:16 AM, and then notified the facility that resident #1 was found and would be transferred to the hospital to be evaluated for complaints of back and knee pain. On 2/15/23 at 7:32 PM, in a telephone interview, the responding police officer recalled on arrival at the gas station, resident #1 could not tell her where he was from, but he eventually provided his name. She stated the resident looked dirty and seemed very disoriented. She stated she was told resident #1 went into the convenience store to get food and someone might have given him a sandwich because she noticed a wrapper beside him. The police officer recalled it had been raining intermittently all night and the resident looked like he was cold. She said, He was definitely in an unsafe situation. The Fire Department transported him to [name of a hospital], but if they hadn't, we would have taken him. In that state, we would not have left him behind. She stated the area around the convenience store was not necessarily a high-crime area, but there were frequent motor vehicle accidents at that intersection, and the main thoroughfare was very busy. On 2/16/22 at 12:09 AM, in a telephone interview, the convenience store employee explained he called the police when he became concerned about a man who had been outside the location at night for two to three days. He said, Something was off about him. I did not see where he slept but I assume he slept at the tables. The facility is located on a moderately to heavily trafficked two-lane road, across from an elementary school. It is approximately 400 feet away from a large, heavily trafficked major intersection of two 7-lane divided highways. The area around the facility was densely populated with a mix of commercial and residential properties and a university. Resident #1 would likely have walked along the major thoroughfare and crossed multiple busy intersections, side streets, driveways, and parking lots before he arrived at the convenience store almost four miles away. It is unknown if resident #1 crossed the major road where there was a large lake (retrieved on 2/24/23 from www.googlemaps.com). The temperatures during the period resident #1 was away from the facility, 2/09/23 to 2/12/23, ranged from 60 to 84 degrees Fahrenheit. On 2/09/23 between 10:00 PM and 12:00 AM, there was rain and thunderstorms. On 2/10/23 at approximately 4:00 PM, and on 2/12/22 between 1:00 AM and 3:30 AM there was rain (retrieved on 2/16/23 from www.timeanddate.com). On 2/14/23 at 8:13 PM, resident #8 stated on the day resident #1 eloped, she was seated in the lobby waiting for transportation to an appointment. She explained she dozed off and was awakened when her driver arrived. Resident #8 recalled the driver pushed her wheelchair through the front doors and when they arrived at the gate that led to the parking lot they encountered a man who appeared to be having difficulty opening the latch and he seemed a little confused. She stated the driver opened the latch and the man held the gate open for them. Resident #8 stated the driver thanked him, and she did not see where the man went afterward. On 2/14/23 at 7:00 PM, CNA C stated she was assigned to resident #1 on the 3:00 PM to 11:00 PM shift on the day he eloped. She explained earlier that day, on the 7:00 AM to 3:00 PM shift, she was assigned to residents on the opposite side of the hallway from resident #1's room. CNA C stated her hall partner CNA B was assigned to resident #1's room for the day shift. She recalled she took over CNA B's side of the hallway as her new assignment at 3:00 PM but did not do change of shift walking rounds with CNA B. CNA C stated the last time she saw resident #1 was at lunchtime while she was distributing meal trays. She said, I had to get up another resident at family request. I did not take report from her that day because we were working together and I saw her residents through the day shift.When you get busy you don't always have the time. CNA C recalled she was in a room with a resident when the nurse asked if she had seen resident #1. After completing that task, she went to look for resident #1 and noted he was not in bed or the bathroom. She stated someone used the overhead paging system to announce a Code Green to alert all staff to a missing resident situation. On 2/15/22 at 12:08 PM, CNA A stated she was regularly assigned to care for resident #1 on the 7:00 AM to 3:00 PM shift. She explained he usually stayed in his room except for the days when he went to the shower room. She recalled on the day he eloped, he was dressed in red shorts, a black short-sleeved shirt, and socks when she went in to remove his lunch tray at about 12:45 PM. CNA A stated all residents were to be checked at least every 2 hours, and every 30 to 60 minutes if at risk for wandering or elopement. She acknowledged CNAs were expected to walking rounds during change of shift report, but she did not follow protocol and do this with CNA C that day. CNA A said, Some staff will do it and others won't. On 2/14/23 at 8:17 PM, Registered Nurse (RN) A stated he was assigned to resident #1 on the 3:00 PM to 11:00 PM shift on 2/09/23. He explained he arrived at 3:00 PM but did not get report until 3:45 PM as the day shift nurse, RN D was still busy with residents. RN A stated he noticed resident #1 was not in his room when he went to administer medication to the roommate. RN A stated the roommate informed him resident #1 was dressed in regular clothing as if he were going out with his family. RN A said, I went to check the appointment list and didn't see his name. Then I realized there was a problem. On 2/17/23 at 11:20 AM, RN D stated on 2/09/23 she was resident #1's assigned nurse for the 7:00 AM to 3:00 PM shift. She recalled the resident was in his room eating lunch at about 12:30 PM when she administered medications to the roommate. She explained there was no specified frequency for rounds, but she checked on resident as her heavy workload allowed. RN D stated at the end of her shift, she gave report to the oncoming nurse, RN A, and left the facility. She confirmed she did not conduct walking rounds with RN A to verify the status or location of their residents during change of shift report. Review of the facility's policy and procedure for Elopements revised on 7/13/22 read, This facility ensures that residents who are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to their elopement risk. Adequate supervision will be provided to help prevent accidents or elopements. The document indicated residents would be assessed for elopement risk on admission and regularly throughout their stay in the facility, and the interdisciplinary team would develop care plan approaches that addressed unique risk factors for each resident. On 2/14/23 at 5:44 PM, the Administrator, Director of Nursing (DON) and Regional Nurse Consultant (RNC) discussed the facility's elopement incident investigation. The facility determined the root causes of resident #1's elopement included visual observation of door was not done and his past lifestyle was not considered in determining his risk for elopement. However, the root cause analysis did not show nursing staff failed to offer the minimum level of supervision required by monitoring the resident's whereabouts at least every two hours. The Administrator explained the facility did not have an electronic system that alarmed when residents who wore wander monitoring devices approached exterior doors. He said, We rely on staff supervision and monitoring of residents. Alarms can lull you into a false sense of security. The DON verified assigned CNAs and nurses did not do change of shift walking rounds at 3:00 PM, and no staff noticed the resident was missing for three hours. The Administrator acknowledged by the time law enforcement was notified and a K-9 officer arrived with a dog, the resident had been missing for approximately four hours. He stated the K-9 officer retrieved the resident's pillowcase to obtain his scent but the dog only tracked the resident for a short distance headed south along the major thoroughfare before losing his scent. On 2/14/23 at 6:30 PM, the Staff Development Coordinator (SDC) stated she participated in the root cause analysis conducted by the Quality Assurance and Performance Improvement committee. The SDC stated she was aware there were issues with change of shift rounding not being completed as required. She said, Staff might be in a hurry or have to leave early. The SDC acknowledged education regarding nursing change of shift rounds to verify the location and status of residents and to ensure rooms were free of clutter and hazards, began only within the past 30 minutes. Review of the Facility Assessment dated 3/10/22 revealed the facility could provide care for residents with psychiatric, mood and neurological conditions including anxiety, depression, and dementia. Available services included mental health and behavior management. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 2/09/23 at 4:09 PM, a complete head-count by nursing staff confirmed all residents of facility were present, except resident #1. *On 2/09/23, the nursing management team completed elopement risk evaluations on all residents and no new residents were identified as at risk. The elopement risk binders were reviewed by the DON to validate that each resident at risk for elopement had demographic information in the binder. *On 2/09/23, the Staff Development Coordinator (SDC) initiated all staff education the facility's policy for prevention of Abuse, Neglect and Exploitation, with an emphasis on Neglect, to include reporting requirements, elopement standard and guidelines, responding to door alarms and proper actions to take upon responding, and maintaining visual observation of all persons entering and exiting the facility. A post-test was used to validate comprehension of education received. The facility achieved 100% compliance on 2/16/23. *On 2/09/23, the DON reviewed clinical records of residents identified to be at risk for elopement to confirm elopement risk care plans were in place. Residents were confirmed to have orders in place for increased monitoring, behavior monitoring for exit seeking, interventions attempted for exit seeking and outcome of those interventions. *On 2/09/23, the button that allowed staff to open the front lobby doors remotely, without direct supervision of the doors, was removed by the Maintenance Director. The front desk staff were educated by the Administrator on only opening the front lobby doors at the keypad next to door. *On 2/09/23, the Maintenance Director relocated the receptionist's desk to an area that allows direct supervision of the door. *On 2/10/23, the Receptionist job description was revised by the Administrator to include maintaining visual observation of persons entering and exiting the front door. *On 2/10/23 at 5:30 AM, the Maintenance Director checked egress doors for alarms and function with no issues identified. *On 2/10/23, elopement drills were initiated on the 11:00 PM to 7:00 AM shift and conducted every shift until the 11:00 PM to 7:00 AM on 2/16/23. Elopement drills will be ongoing, conducted weekly on alternating shifts until it is determined by the QAPI committee that it is appropriate to decrease the frequency to monthly on alternating shifts. *On 2/10/23, the facility held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting. Attendees included the Medical Director. The committee reviewed QAPI minutes and accepted the Performance Improvement Plan. *On 2/12//23, resident #1 was found by law enforcement, transported to the hospital for evaluation, and returned to the care of the facility at approximately 11:20 AM. The DON completed a head-to-toe assessment of resident #1 and noted blisters to both feet and scabbed areas to his right hand and right arm. *On 2/12/23, resident #1 was assessed for elopement risk and identified as high risk. His photo and demographic information were placed in the Elopement Risk Binder. The resident was placed on one-to-one supervision immediately, and will remain with that level of supervision until otherwise determined by the interdisciplinary team. *On 2/12/23, the RNC and members of the facility's management team reviewed and revised the facility's Elopement Evaluation form to include additional risk factors of history of homelessness and substance abuse. All current residents were re-evaluated for elopement risk by the nursing administrative team and one new resident was identified as at risk. *On 2/14/23, Elopement Binder Quality Monitoring (QM) reviews were completed. A Quality Review re: elopement process was completed. *On 2/16/23, the facility achieved 100% with education provided by the SDC for nursing staff on rounding during and between shifts. Agency staff and newly hired staff will be educated during the orientation process or prior to starting their next shift. *On 2/17/23, the QAPI committee reviewed results of elopement drills to determine any need for systematic change. Staff elopement education validation QM and staff rounding QM tool were completed. *On 2/17/23, the facility held an Ad Hoc QAPI committee meeting to review current QAPI Performance Improvement Plans to determine the need for further changes. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on topics listed above. On 2/17/23, interviews were conducted with 20 agency and facility staff representing all shifts. The Activities Director, one laundry staff, five RNs, four LPNs, and nine CNAs verbalized understanding of the education provided. The resident sample was expanded to include five additional residents who were at risk for elopement. Observations, interviews, and record reviews revealed no concerns for residents #2, #3, #4, #5, and #6 related to accuracy of elopement evaluations and appropriateness of person-centered care plan interventions.

Based on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to oversee the implementation of policies and procedures and interdisciplinary team (IDT) processes to meet the safety and care needs of 1 of 11 residents reviewed for braces and elopement, (#1); and failed to identify and mitigate vulnerabilities in security of the front lobby and all exterior exit doors to prohibit unauthorized egress of 1 of 6 residents reviewed for elopement, (#1), of a total sample of 12 residents. These failures contributed to preventable complications related to brace use, and the elopement of resident #1, and placed him at risk for serious infection/injury/impairment/death. While resident #1 was out of the facility unsupervised, there was a likelihood he could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On 8/22/22, resident #1 was admitted to the facility with a brace in place for a left wrist fracture. Facility staff did not obtain orders for necessary care and services, the device was never removed for skin evaluation, and the resident's left hand and arm were not assessed regularly. Resident #1 developed a wound and a skin infection under the brace and was transferred to the hospital on 9/10/22 for treatment. He required wound care, intravenous antibiotics, and consultation with an orthopedic specialist during his hospitalization. On 9/13/22, the resident was readmitted to the facility with a new brace. Nursing staff did not follow hospital discharge orders for follow up with the orthopedic specialist within two weeks. Over the next five months, resident #1's plan of care was not updated to reflect the frequency and duration of use of the device, and therapy orders were not obtained and implemented to promote optimal functional status. On 2/09/23 at approximately 1:00 PM, resident #1 left his room and walked towards the facility's front lobby unnoticed by staff. When the receptionist opened the front doors for incoming transportation personnel, she did not maintain focus on the doors and resident #1 left the building simultaneously. Nursing staff did not conduct rounds at the change of shift, and resident #1's assigned nurse did not notice he was missing until approximately 4:00 PM. On 2/12/23 at approximately 4:00 AM, a concerned citizen contacted law enforcement regarding the well-being of a man loitering at a gas station over three miles away from the facility. Law enforcement responded, identified the man as resident #1, and arranged medical transport to the hospital. The facility was unaware of resident #1's whereabouts for three days until law enforcement notified the Administrator he was found. The facility's failure to implement policies and procedures to develop appropriate plans of care and prevent neglect; and failure to maintain a safe and secure environment placed all residents who had braces and/or wandered at risk. These failures resulted in Immediate Jeopardy starting on 8/22/22. The Immediate Jeopardy was removed on 2/17/23. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F600, F607, F684, and F689. On 2/17/23 at 4:06 PM, the Administrator stated he had been on staff for approximately six weeks, and the Director of Nursing (DON) stated was hired about 10 weeks ago. He explained the issue with resident #1's splint occurred prior to their tenure. The Administrator acknowledged the facility's nursing management and the IDT were expected to function effectively and smoothly to implement all policies and procedures despite changes in staff. He explained the facility's administrative and management teams had scheduled meetings with defined content, purposes, and formats. The Administrator stated the daily Morning Meeting lasted about 30 minutes and was attended by all department heads and support staff. He explained department managers were expected to focus on issues related to the primary responsibilities of each department. The DON stated the Morning Meeting was followed by the clinical team meeting, which was attended by the Minimum Data Set nurse, nursing management including herself, the Director of Rehab, and the Administrator. The Administrator and DON validated the factors that contributed to resident #1's wound, skin infection, hospitalization, lack of orthopedic follow up, and elopement were not identified during daily meetings from August 2022 to February 2023. On 2/17/23 at 9:29 AM, the Director of Maintenance was asked to clarify the log posted to the left of the front lobby doors that indicated the doors were not checked on the weekends. He stated he checked the function of locks and alarms on all exterior egress doors daily, Monday through Friday. He acknowledged if the task was not done on Saturdays and Sundays it was a weakness in the facility's security. The Director of Maintenance said, I don't think the Administrator is aware doors are not being checked on the weekend. I planned to tell him. I will speak with him. On 2/17/23 at 9:34 AM, during observation of the front lobby doors and review of the door log with the Director of Maintenance, the Administrator approached. He was shown the log with blank boxes in the columns designated for Saturday and Sunday. He stated he was not aware the facility's exterior exit doors were not being checked on the weekends. The Maintenance Director told the Administrator he had been planning to tell him. The Administrator confirmed the issue was never brought to his attention in daily meetings and he never noticed the blank spaces on the log which was prominently post beneath the keypad. Review of the Facility Assessment dated 2/10/22 revealed the facility could care for residents with common diagnoses including depression, stroke, dementia, and fractures. Based on residents' needs, services and care included daily activities of daily living care, mental health and behavioral support for dementia and wandering. The document indicated the facility provided rehabilitation services such as Occupational Therapy to assist with recovery from illness or injury and maintain skills for daily life. The Facility Assessment revealed the Medical Director would oversee the quality of medical care, attending physicians were responsible for all aspects of residents' medical care, and Advanced Practice Nurse Practitioners would assess residents and develop treatment plans. The document showed the facility's training program included the topics of effective communication, resident rights and special needs, prevention of Abuse and Neglect, dementia management, and caring for the cognitively impaired. The job description for Director of Nursing dated August 2021 revealed she was responsible for management of the overall operations of the Nursing Department. The DON's responsibilities included participating in meetings and directing the delivery of nursing services. The job description for Administrator dated December 2018 revealed he would lead and direct the overall operations of the facility.with focus on maintaining excellent care for the residents. His essential duties and responsibilities included monitor each department's activities, communicate policies, evaluate performance. The Administrator was expected to consult with department managers to address concerns and/or improve services. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 2/10/23, the receptionist's desk was temporarily relocated to the entry way, so he/she has a direct line of vision and is better able to monitor the front door. The button to open up the door has been deactivated and a staff member now needs to manually put in code at door site. This is a temporary solution until a permanent alternative is put in place. *On 2/10/23, the RNC educated the DON related to morning Clinical Meetings and the identification of device orders for new admissions/re-admissions, and current residents. *On 2/16/23, the Regional Director of Operations (RDO) reviewed the Administrator's job description, including understanding of allocating staff appropriately and efficiently to safely care for all residents. The RDO educated the Administrator on eliciting additional support services through regional team members and how to use resources effectively. The Administrator verbalized understanding. *On 2/16/23, the Regional Nurse Consultant (RNC) reviewed the Director of Nursing's job description, including understanding of allocating staff appropriately and efficiently to safely care for all residents. The Director of Nursing verbalized understanding. *As of 2/16/23, staffing is being reviewed daily by the Administrator and DON/or designee to ensure appropriate levels. Staffing will be adjusted as needed. *On 2/16/23, the RNC educated the Administrator and DON on the Quality Assurance and Performance Improvement process, and how to perform data analysis from the audits conducted to evaluate if performance improvement plans are effective or need to be redefined. Interviews conducted with the Administrator and DON on 2/17/23 revealed they received education on the above topics.