**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to implement the plan of care for one resident (R) R#1 with a known history of elopement, to perform frequent location checks of exit seeking behavior from a sample of eight residents. On 6/5/23 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Infection Preventionist were informed of the Immediate Jeopardy (IJ) on 6/5/23 at 1:00 p.m. The noncompliance related to the IJ was identified to have existed on 5/16/23. An Acceptable IJ Removal Plan was received on 6/9/23. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 6/9/23. Findings include: R#1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: schizophrenia, major depressive disorder, acute encephalopathy, hypertension, schizoaffective disorder, auditory and visual hallucinations, diabetes mellitus type II, bipolar, communication impairment, neurological muscle weakness, risk of elopement from cognitively impaired subject, and wandering. The resident had a Quarterly Minimum Data Set assessment completed on 4/24/23 indicating a Brief Interview for Mental Status (BIMS) of 0 indicating the resident had severely impaired cognition, having no behaviors or wandering behavior, independent for transfers, and supervision with ambulation. The resident had a care plan since 11/22/21 for elopement behaviors managed to prevent harm, wanders at night and history of opening windows or checking to see if doors are locked with the following interventions: perform frequent location checks if exit seeking behavior and utilize Wander Alert device. There was also a physician's order since 11/5/21 to monitor resident for exit seeking behaviors six times per day following 9/29/21 incident (eloped from facility). Review of the Safety Checks TAR revealed the resident was not monitored for exit seeking behaviors six times a day as ordered by the physician. The document revealed on 5/8/23 monitored twice, 5/9/23 and 5/10/23 monitored three times, 5/11/23 monitored twice, 5/12/23 and 5/13/23 monitored once, 5/14/23 monitored twice, and 5/15/23 monitored once. On 5/16/23 staff documented they monitored the resident at 1:41 p.m. and at 5:44 p.m. although the resident had already eloped from the facility. During an interview with LPN AA on 5/30/23 at 1:35 p.m. she stated she checked the resident's blood sugar on 5/16/23 around 11:00 a.m. or 11:30 a.m. and last saw the resident between 11:30 a.m. or 12:00 p.m. walking around Station 2 where his room was. She stated she made up the resident's blood sugars and falsified the documentation. At 4:30 p.m. she to look for the resident to check his blood sugar but she did not see him in his room, and she didn't even think to go and look for him, she just continued to go and check other resident's blood sugars. She stated she was supposed to do two-hour checks on her residents, but she was so far behind that day. She also stated that none of the staff had reported the resident's meal trays being untouched to her. During an interview with CNA BB on 5/25/23 at 4:55 p.m., she stated she last saw the resident on 5/16/23 around 11:30 a.m./12:00 p.m. when she was passing out lunch trays. She stated that she thought an agency CNA had delivered the resident's supper tray later that day. She stated that she was new to this and had gotten her CNA certification in April 2023 and she did not realize she was supposed to make rounds every two hours on the residents. There was no evidence the facility staff performed the frequent location checks on 5/16/23 as outlined in the care plan which resulted in the resident being missing for approximately eight hours before staff realized the resident had eloped from the facility. The resident was not found until nearly 21 hours later under an overpass on I-75 approximately 2.5 miles from the facility. The facility implemented the following actions to remove the IJ: (1) Resident # 1 is currently residing at Crisp Regional Health and Rehab and continues to have routine consults with the MD. His care plan was reviewed and revised on 5/17/2023 and 6/6/2023 by the Lead MDS to reflect the current elopement status high risk. Hourly rounds are being performed and wanderguard safety checks daily as indicated on the care plan. (2) On 05/17/2023, the policy for Elopement and LTC Care Plans were reviewed by the Administrator, LTC Quality Administrator, VP of LTC, and MDS Lead with no revisions made. The Medical Director reviewed and approved the Elopement Policy on 6/8/2023. (3) On 05/17/2023 and again on 06/06/2023, the MDS lead reviewed elopement care plans on 60 of 60 residents. There are 6 residents out of 60 residents identified at high risk for elopements. The care plans were updated to reflect all elopement interventions and the assessment questions as reflected in the LTC Elopement Policy. (4) On 06/07/2023, the Lead MDS in-serviced the IDT, which consists of SSD, MDS nurse, Unit Managers, Dietary Manager, Activity Director, Rehab Director, Wound Nurse, Admissions Director, Infection Control Nurse, Medical Records Director, Maintenance Director, and Administrator on development/ implementation of Elopement Care Plans. (5) On 06/06/2023, the Lead MDS implemented a Hourly Elopement Risk Rounding tool to audit residents identified as high risk for elopements with every 1-hour rounding, 24 hours 7 days/week. This audit includes wander guard system checks daily which includes testing the wanderguard bracelet to guarantee when in the vicinity of the (2) functioning door, the alarm sounds and locks appropriately. (6) On 6/6/2023 The MDS Lead implemented an Elopement Book at each nurse's station, inclusive of the Elopement Policy, all high risk for elopement resident profiles, pictures and care plans for easy access to all staff. All staff (10 of 10 RNs, 12 of 12 LPNs, 25 of 25 CNAs, 5 dietary, 1 of 1 materials management, 2 of 2 of maintenance, 6 of 6 housekeeping, 4 of 4 Therapists, 1 of 1 SSD, 1 of 1 BOM, 5 of 5 agency CNAs, and 5 of 5 agency LPNs, totaling 77 employees) have been educated where to access the elopement care plans by the RN MDS Lead and RN QA Nurse between 6/6/23 - 6/8/23. The remaining 18 PRN employees will be in-service prior to the next shift worked by the RN Nurse Educator, MDS Lead, Clinical Coordinator and/or Director of Nursing. (7) The Administrator and/or Director of Nursing will review the results of the audits daily starting 6/8/2023 to determine compliance. If a deficient practice is identified, it will be corrected immediately in an ADHOC QAPI and reviewed monthly in QAPI. (8) On 6/7/2023 the Quality Nurse implemented an Elopement Risk QAPI Audit Tool inclusive of the following that will be reported at each QAPI meeting: a. Number of elopement attempts, resident that attempted elopement, interventions put in place and care-plan review. b. Any residents exhibiting new exit seeking behaviors, interventions put in place and care-plan review. c. Audit that all required Elopement assessments are complete in correlation with new admissions, changes in condition and quarterly as indicated by the MDS assessment schedule. (9) An ADHOC QAPI meeting was held 5/26/2023 reviewing the elopement event that took place and the interventions in place. A second ADHOC QAPI meeting related to the incident was held 6/7/2023 to review the monitoring and audit tools implemented including the Hourly Elopement Risk Tool and the QAPI Elopement Risk Audit Tool. (10) Date corrective action will be completed is 6/8/2023 and IJ to be removed on 6/9/23. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: (1) R#1 remains as a resident at the facility and this was verified via review of facility census data, dated 6/11/23 and review of R#1's clinical record, which included R#1's elopement risk care plan. Review of the Hourly Elopement Risk Rounding forms from 5/17/23 through 6/11/23 revealed that hourly rounds and daily wander guard safety checks were being completed by staff. This information was further verified via interview with the Administrator on 6/13/23 at 11:18 a.m. (2) Review of the LTC Elopement Policy with revision date of 6/2023 was verified. The policy included care plan procedures related to elopement. The policy was signed by the facility CEO, Director/VP of LTC, and the LTC Quality Administrator. A typed and signed statement, dated 6/8/23 from the Medical Director confirmed his agreement with the LTC Elopement plan. Also verified via interviews on 6/12/23 at 11:27 a.m. with the MDS Lead, on 6/13/23 at 11:18 a.m. with the Administrator, and on 6/13/23 at 12:20 p.m. with the LTC Quality Administrator. (3) Review of the elopement risk score sheets revealed they were completed on all residents on 5/17/23 and again on 6/6/23. A review of the elopement risk score sheets revealed that the initial six residents identified at high risk for elopement on 5/17/23 were R#1, R#2, R#3, R#4, R#5 and R#7. An additional resident, R#6, was also identified as high risk for elopement on 6/7/23. During an interview on 6/12/23 at 2:45 p.m. the DON confirmed the residents identified as being high risk for elopement and stated that monitoring of R#7 stopped, and he was no longer high risk, due to a change in condition. R#6 was a new admission on [DATE]. Review of the care plans for R#1, R#2, R#3, R#4, R#5, R#6, and R#7 revealed they were updated to include elopement risk and interventions. (4) Review of In-service education information titled Elopement IPOC's/Care-Plans with the accompanying staff signature sheets, dated 6/7/23 confirmed education provided to IDT. Also verified via interviews on 6/13/23 at 11:18 a.m. with the Administrator and at 11:45 a.m. with the Infection Control Nurse. Confirmed via interview with the Lead MDS on 6/12/23 at 11:27 a.m. she in-serviced the IDT team on the development/implementation of elopement care plans. Staff interviews conducted on 6/12/23 at 11:23 a.m. with Activities Director DD, at 11:40 a.m. with MDS coordinator GG, at 11:45 a.m. with Unit Manager HH, at 12:14 p.m. with the Medical Records Director, at 12:34 p.m. with the SSD and at 2:00 p.m. with the Dietary Manager and on 6/13/23 at 10:43 a.m. with the Maintenance Director confirmed they had received the in-service on the development/implementation of elopement care plans. (5) Record review of the Hourly Elopement Risk Rounding tools confirmed completed on all residents identified as high risk for elopements. Also verified via review of the QAPI Elopement Risk audit tools completed by the Administrator from 6/8/23 through 6/12/23. Interview with the Lead MDS on 6/12/23 at 11:27 a.m. who reported that she implemented the Hourly Elopement Risk Rounding tool for residents identified as high risk for elopement. (6) During an interview on 6/12/23 at 11:55 a.m., the RN QA Nurse (who is also the RN Nurse Educator) verified that the in-service education had been completed with all full-time facility staff (in person and/or over the phone) and that the 18 remaining PRN staff would be in-serviced prior to the next shift worked. She stated that she completed the in-service education with day shift staff and the MDS Lead completed in-service education with night shift staff. Review of the in-service education information and staff signature sheets titled Compliance and Ethics, IC P&P, Elopement Policy/IPOC, dated 6/6/23 through 6/8/23 revealed that 10 RN's, 12 LPN's (including 5 agency LPN's), 25 CNA's (including 5 agency CNA's), 5 dietary staff, 1 materials management staff, 2 maintenance staff, 6 housekeeping staff, 4 therapy staff, 1 SSD, and 1 BOM received the in-service education. Staff interviews conducted on 6/12/23 at 11:10 a.m. with CNA CC, at 11:23 a.m. with the Activities Director, at 11:25 a.m. with CNA EE, at 11:36 a.m. with Rehab Tech FF, at 11:40 a.m. with MDS Coordinator GG, at 11:45 a.m. with RN, Unit Coordinator HH, at 11:52 a.m. with Business Office Manager, at 11:55 a.m. with Infection Control, QAPI Nurse and Education Nurse, at 12:07 p.m. with CNA II, at 12:11 p.m. with LPN JJ, at 12:14 p.m. with Medical Records Director, at 12:17 p.m. with CNA KK, at 12:21 p.m. with LPN LL, at 12:34 with the SSD, at 12:57 p.m. with PTA MM, at 1:00 p.m. with HK/Floor Tech NN, at 1:04 p.m. with RN Weekend Supervisor OO and LPN PP, at 1:06 p.m. with the HK Manager, at 1:10 p.m. with Therapy/Office QQ, at 1:15 p.m. with CNA RR, at 1:23 p.m. with Respiratory Therapist SS, at 1:35 p.m. with Vent Unit Coordinator/RT TT, at 1:52 p.m. with HK UU and Vent Unit RN VV, at 1:55 p.m. with HK/Laundry WW, at 2:00 p.m. with the DM and HK XX, at 2:21 p.m. with Dietary Aide YY, at 2:24 p.m. with CNA BB, at 2:25 p.m. with Dietary ZZ, at 2:45 p.m. with the DON, at 3:03 with HK AAA, at 4:24 p.m. with CNA BBB, at 4:35 p.m. with CNA CCC, at 4:37 p.m. with LPN DDD, on 6/13/23 at 9:20 a.m. with LPN FFF, at 9:27 a.m. with CNA GGG, at 9:30 a.m. and at 10:43 a.m. with the Maintenance Director confirmed they had received in-service training on the Elopement books, Elopement Policy, Elopement resident profiles and care plans. (7) Verified via review of the QAPI Elopement Risk Audit Tools signed and dated 6/8/23 through 6/12/23 by the Administrator. The completed audit tools included all residents identified as high risk for elopement. During an interview on 6/13/23 at 11:18 a.m. the Administrator confirmed completion of the tools and review of the results. (8) Verified via review of the QAPI Elopement Risk Audit Tool which included the categories of elopement attempts, residents exhibiting exit seeking behaviors, elopement assessments, hourly elopement risk and wander guard safety check audit. During an interview on 6/12/23 at 11:55 a.m. the Quality Nurse confirmed the use of the tool and that the results of the audits would be discussed at the next QAPI meeting scheduled for 6/30/23. (9) Verified via review of the QAPI signature sheet, dated 5/26/23 and the accompanying QAPI meeting information, which included the topic of elopement and elopement POC. Also verified via review of the QAPI ADHOC meeting information and accompanying staff signature sheet, dated 6/7/23. The agenda included elopement and the audit tools implemented. Also verified via review of the Elopement PIP accepted by the QA committee on 6/7/23. During an interview on 6/13/23 at 11:45 a.m., the Quality Nurse confirmed the meetings were held on 5/26/23 and 6/7/23 and included discussions on elopement, interventions in place, and use of the monitoring and audit tools. She stated the next QAPI meeting was scheduled for 6/30/23. During an interview on 6/13/23 at 11:18 a.m., the Administrator also confirmed the QAPI meetings and elopement discussion. (10) All corrective actions were corrected on 6/8/2023 and the immediacy of the IJ was removed on 6/9/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility policy titled, Elopement, the facility failed to provide adequate supervision and frequent monitoring of resident (R) #1 and failed to ensure one of three doors equipped with the Wander Guard system was functioning to prevent the elopement of one resident R#1 from a sample of eight residents. On 6/5/23 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Infection Preventionist were informed of the Immediate Jeopardy (IJ) on 6/5/23 at 1:00 p.m. The noncompliance related to the IJ was identified to have existed on 5/16/23. An Acceptable IJ Removal Plan was received on 6/9/23. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 6/9/23. Findings include: Review of the facility policy titled Elopement with a revision date of 11/2021 revealed the following: Residents who wander are considered an elopement risk, and the facility will ensure that the safety of residents who wander is maintained, and that elopement is prevented; All of the unit's staff members are aware which residents are an elopement risk and are familiar with their care plans; All of the unit's staff members are familiar with the plan of action in the event of a resident elopement; If a resident tries to follow a staff member through the door of a locked unit, the staff member should reverse direction, and then distract to prevent the resident feeling locked in or confined. R#1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: schizophrenia, major depressive disorder, acute encephalopathy, hypertension, schizoaffective disorder, auditory and visual hallucinations, diabetes mellitus type II, bipolar, communication impairment, neurological muscle weakness, risk of elopement from cognitively impaired subject, and wandering. The resident had a Quarterly Minimum Data Set assessment completed on 4/24/23 indicating a Brief Interview for Mental Status (BIMS) of 0 indicating the resident had severely impaired cognition, having no behaviors or wandering behavior, independent for transfers, and supervision with ambulation. The resident had a care plan since 11/22/21 for elopement behaviors managed to prevent harm, wanders at night and history of opening windows or checking to see if doors are locked with the following interventions: perform frequent location checks if exit seeking behavior and utilize Wander Alert device. The resident had an elopement risk score of 75 on 5/2/23 indicating the resident was at risk for elopement. The assessment also indicated the resident had a history of elopement attempts, wandering, was independent with mobility and had impaired short-term memory. There was also a Physician's order since 11/5/21 to monitor resident for exit seeking behaviors six times per day following 9/29/21 incident (eloped from facility). Review of the Safety Checks TAR revealed the resident was not monitored for exit seeking behaviors six times a day as ordered by the physician on the following dates: on 5/8/23 monitored twice, 5/9/23 and 5/10/23 monitored three times, 5/11/23 monitored twice, 5/12/23 and 5/13/23 monitored once, 5/14/23 monitored twice, 5/15/23 monitored once, 5/16/23 staff documented they monitored the resident at 1:41 p.m. and at 5:44 p.m. although the resident had already eloped from the facility. Review of the Wander Guard Functioning Log Weekly Check forms revealed the Wander Guard was checked weekly and was last checked on 5/8/23 prior to 5/16/23. However, the documentation did not include which doors were checked that were equipped with the Wander Guard system. During an interview with the Maintenance Supervisor on 5/24/23 at 3:35 p.m., he stated three doors are equipped with the Wander Guard system and he only checks one of the three doors each week by walking R#1 up to the door. He stated the front door was last checked three weeks prior to the elopement incident on 5/16/23 and was working at that time. On 5/18/23 at 2:23 p.m. observations were made with the Maintenance Supervisor of the three doors equipped with the Wander Guard system by walking R#1 up to each door. During this observation the front door alarm did not sound when R#1 walked out the door. Review of the 5/17/23 2:46 a.m. Progress Notes documented that at 8:20 p.m. on 5/16/23 staff was looking for resident to administer p.m. medications and activities of daily living (ADL) care. The resident was not in his room. The writer then proceeded to call station one to see if the resident went to visit that side of the building. The resident was not located. The family was called at 8:40 p.m. to see if relatives had come to get him for a home visit. All in house staff searched building, every room from 8:40 p.m.- 9:15 p.m. The resident was not located. At 9:31 p.m. notified facility on call nurse who then contacted the Director of Nursing (DON) and received orders at 9:39 p.m. to notify family and 911 and follow Elopement policy. Elopement alert went out to all day shift nurses and managers at 9:40 p.m. 911 arrived at facility at 10:25 p.m. All staff and 911 proceeded to search premises, additional staff searched on and off premises and surrounding neighborhood in personal vehicles. Two Certified Nursing Assistants (CNA) searched east and west areas of neighborhood. Available staff, social worker, Administrator, Human Resources Administrator, Maintenance Supervisor along with 911 searched for resident in different areas. Resident has not been located. Silver alert broadcasted at 1:29 a.m. The Nursing Narrative Note dated 5/17/23 at 11:00 a.m. indicated the DON was alerted by authorities that R#1 was observed to be outside near facility. Emergency Medical Services (EMS) picked resident up and all vitals were within normal limits upon initial assessment. Resident stated he felt fine and was laying down when observed initially. EMS stated resident jumped up and started walking without difficulties. Resident drank two Gatorades given by EMS. Resident returned to facility via EMS at 10:00 a.m. Vitals were obtained: 129/57, 103, 97.6, 18 and 97% on room air. Blood sugar was 217. Stat labs were drawn as ordered by physician. At 10:15 a.m. resident had a skin assessment completed and a bath was given. At 10:45 a.m. the Physician and Nurse Practitioner did an evaluation of the resident with no new orders. Resident was given a tray and ate 100%. Resident was resting in his room following his meal. Review of the 5/17/23 Nurse Practitioner progress note revealed the resident was seen secondary to elopement yesterday. Patient was seen and evaluated with physician with patient being in no acute distress. Status post elopement this gentleman who was found under exit 104 bridge, returned by EMS in no acute distress. Review of the 5/16/23 local Sheriff's Office Incident Report revealed the Deputy was dispatched to the facility on 5/16/23 at 10:15 p.m. and was advised by staff that one of the patients was missing. The Deputy reviewed the camera system but was unable to pinpoint exactly where R#1 left the building due to some of the cameras not having video and some of the videos skipping. He was able to locate the resident on video at 12:30 p.m. near the front nurse station. The deputy spoke to staff that identified herself as the [NAME] President of the facility and told the deputy that she had contacted the employee that was responsible for checking the resident's blood sugar. She stated she found out her employee had lied about checking R#1's blood sugar at 4:30 p.m. She reported the last time anyone at the facility accounted for R#1 was at 12:30 p.m. Review of the timeline for 5/16/23-5/17/23 provided by the Administrator revealed the following: 5/16/23- 8:00 p.m. LPN arrived 8:20 p.m.- LPN began to give medications and could not find the resident. 8:40 p.m. called resident's sister who stated the resident was not with her. 9:00 p.m.- CNA was looking resident in his room and observed the lunch and dinner trays were still in his room. 9:41 p.m.- on call nurse informed of elopement. 9:43 p.m.- DON called the Administrator. 9:44 p.m.- informed nurse to initiate plan. 9:45 p.m.- called LPN AA who initially stated she checked the resident's blood sugar at 3:30 p.m. She then came back and admitted she did not check his blood sugar and had not laid eyes on him since 12:00 p.m. LPN AA documented she checked the blood sugar and administered glimepiride on the Medication Administration Record (MAR) at 5:44 p.m. 9:52 p.m.- called CNA BB who last saw resident in his room at lunchtime and walking around. 10:00 p.m.- search crew. 10:19 p.m.- hospital called to see if resident was there. 10:30 p.m.- address of sister received, resident not there. Police arrive to facility. Resident was noted to have left at 12:37 p.m. on 5/16/23 with transport company 5/17/23 at 9:45 a.m. resident was found. EMS returned resident to the facility at 10:00 a.m. Review of the typed statement from the transportation personnel dated 5/19/23 noted the transportation staff documented on 5/16/23 after 12:00 p.m. he was at the facility when he observed R#1 walk out of the front door on the north side of the nursing home near station one. Review of the active physician's orders revealed the following orders: - Blood glucose monitoring four times a day before meals and bedtime with sliding scale insulin - Novolog 70/30 insulin 26 units twice a day - glimepiride (oral diabetes medicine) 4 milligrams (mg) twice a day with meals Review of the May 2023 Medication Administration Record (MAR) revealed LPN AA falsified documentation by documenting she administered glimepiride 4mg on 5/16/23 at 5:44 p.m., and documented she checked the resident's blood glucose at 1:41 p.m. and at 5:44 p.m. although the resident was not in the facility at those times. Further review of the May 2023 MAR revealed the resident had missed the scheduled Novolog 70/30 insulin scheduled for 5/16/23 at 9:00 p.m., scheduled blood glucose monitoring at 9:00 p.m. and the blood glucose monitoring scheduled for 5/17/23 at 8:00 a.m. due to the resident eloping from the facility on 5/16/23 around 12:30 p.m. putting him at risk for a hypo/hyperglycemic episode. During an interview with LPN AA on 5/30/23 at 1:35 p.m. she stated she checked the resident's blood sugar on 5/16/23 around 11:00 a.m. or 11:30 a.m. and last saw the resident between 11:30 a.m. or 12:00 p.m. walking around Station two where his room was. She stated she made up the resident's blood sugars and falsified the documentation. LPN AA reported that on 5/16/23 at 4:30 p.m. she looked for the resident to check his blood sugar but she did not see him in his room and she didn't even think to go and look for him, so she just continued to go and check other resident's blood sugars. She stated she was supposed to do two-hour checks on her residents but she was so far behind that day. She also stated that none of the staff had reported the resident's meal trays being untouched to her. During an interview with CNA BB on 5/25/23 at 4:55 p.m., she stated she last saw the resident on 5/16/23 around 11:30 a.m./12:00 p.m. when she was passing out lunch trays. She stated that she thought an agency CNA had delivered the resident's supper tray later that day. She stated that she was fairly new to this and had gotten her CNA certification in April 2023 and she did not realize she was supposed to make rounds every two hours on the residents. Review of the LPN nurse job description noted the following essential job responsibilities: Effectively and consistently performs basic nursing skills and treatments as prescribed by the physician or as indicated by the patient's condition, Provides assigned patients with quality patient care services consistent with the standards of care established by Nursing Services and the named facility, Documents patient care which reflects appropriate nursing interventions and includes evidence of appropriate patient/family education, Performs associated duties, responsibilities, and tasks relating to safety, infection control, and performance improvement as part of the named facility's efforts to provide quality care and services, Performs rounds every two hours for the purpose of providing quality care and services. Review of the Certified Nursing Assistant Job Description noted the following essential job responsibilities: Alerts the nursing staff and medical staff to observed changes in the patient's condition, Complies with the named facility and developmental safety, infection control, and performance improvement initiatives to ensure the delivery of quality care and services, Performs rounds every two hours for the purpose of providing quality care and services and performs other related job duties as assigned to assure resident safety. During an interview with the DON on 5/31/23 at 11:45 a.m., she stated she does expect staff to make rounds every two hours on the residents and to do a location check on R#1. During an interview with the Administrator on 5/18/23 at 11:15 a.m., she stated that they determined that on 5/16/23 sometime after 12:00 p.m., the resident followed transportation staff out the front door. The transportation person thought the resident was allowed to go out. The staff did not determine the resident was missing until the night shift nurse came on duty and went to give the resident his medications. Day shift had delivered the resident's lunch tray and left it in his room. They then delivered his supper tray and noticed the lunch was untouched but did not look for the resident. They called the Sheriff's department and the police department and had staff from the facility and the hospital looking for the resident all night. He was found the next morning when his cousin was driving down I-75 and saw the resident under the bridge overpass. The resident was assessed by EMT's and brought back to the facility where R#1 was assessed by facility staff. There were no injuries, and his blood sugar was stable. She stated when the EMT's brought the resident back in through the front door they realized the Wander Guard system did not alarm when he came through the front door. Once they identified the front door alarm was not working, they placed staff at the desk at the front door at all times until a new system is installed. The facility implemented the following actions to remove the IJ: (1) Resident #1 is currently residing at Crisp Regional Health and Rehab and continues to have routine consults with the MD. The following interventions were immediately put in place upon his return to the facility: head to toe assessment with no injuries, vital signs and lab work all within normal limits, resident bathed and changed, skin assessment completed, hourly rounds implemented, and daily wanderguard safety checks implemented. No additional elopement have occurred since the incident. (2) The LPN AA responsible for this resident was suspended pending investigation on 5/17/2023 and submitted her resignation on 5/18/2023. The LPN AA license was reported to the licensure board on 5/19/2023. The CNA BB responsible for the resident was suspended pending investigation on 5/17/2023. The CNA BB received education on 5/25/23 regarding rounding on residents, rounding on elopement risk residents, proper timely reporting of residents that have not been seen when performing rounds, as well as the Code Pink Missing Person protocol. The CNA BB received a written corrective disciplinary action on 5/24/23 that will be reviewed on. (3) On 5/17/2023 100% audit of all current residents (60 total) completed by the SSD. 6 residents were identified as high-risk for elopement and placed on hourly rounding by nursing staff. The Hourly Rounding Elopement Risk Tool is being utilized to document hourly rounds by staff. This tool is also being reviewed daily by the Administrator and/or DON Monday - Friday, and the RN supervisor, Director of Nursing and/or Clinical Coordinator Saturday - Sunday. (4) The front door Wanderguard alarm system was identified as ineffective on 5/16/2023, therefore the door has been manned 24 hours/day 7 days/week since and will continue to be until the Wanderguard system is replaced. Approval received for the replacement of the Wandergaurd system upgrade was received on 05/22/2023. Once the equipment is received, the upgrade date will be established. There is 1 entrance/exit door that is not working properly and must be manned 24 hours/day, 7 days/week. There are 3 total Wanderguard entrance/exit doors. If another Wanderguard entrance/exit door stops working properly, the facility will staff the door 24 hours/day 7 days/week. (5) On 5/17/2023 the policy for Elopement and LTC Care Plans were reviewed by the Administrator, LTC Quality Administrator, VP of LTC, and MDS Lead with no revisions made. The Medical Director reviewed and approved the Elopement Policy on 6/8/2023. (6) In-service education for the Elopement Policy and procedures was initiated on 05/17/2023 with completion on 05/23/2023 as well as 6/6/2023 with completion of 6/7/2023. Education was provided by RN Quality Nurse and or MDS Lead to 10 of 10 RNs, 12 of 12 LPNs, 25 of 25 CNAs, 5 of 5 dietary, 1 of 1 materials management, 2of 2 maintenance, 6 of 6 housekeeping, 4 of 4 Therapists, 1 of 1 SSD, 1 of 1 BOM, 5 of 5 agency CNAs, and 5 of 5 agency LPNs, totaling 77 employees were educated on facility Elopement policy and procedures. This is 100% of full time employees. (7) No staff shall work until they have completed the Elopement policy and procedures in-service education. There are 0 staff members that are part time, and 18 staff members that are PRN. These staff members will be in-serviced by the RN Quality Nurse, MDS Lead, Clinical Coordinator and/or Director of Nursing. (8) Newly hired staff will be in-serviced prior to first day on the floor by the RN Quality Nurse, MDS Lead and/or Director of Nursing. No new staff shall work without first receiving education on the elopement policy. (9) Facility implemented interventions on 05/17/2023 which included front entrance/exit manned 24 hours/day 7 days/week, Wandergaurd elopement education, census rounding each shift, 1 hour rounding on high risk residents. On 6/6/2023 elopement books and daily Wanderguard safety checks were implemented for the 2 functioning Wanderguard entrance/exit doors. There are 3 total Wanderguard entrance/exit doors in the facility. (10) New interventions will be monitored by the IDT team to include the Administrator and the DON daily. These interventions will be audited utilizing the QAPI Elopement Audit Tool until 100% compliance is achieved for 6 consecutive months; random audits will continue thereafter. If a deficient practice is identified, it will be addressed in ADHOC QAPI and reviewed monthly in QAPI. (11) Date corrective action will be completed is 6/8/2023 and IJ to be removed on 6/9/2023. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: (1) Verified via review of R#1's clinical record including the 5/17/23 bath sheet documentation, 5/17/23 skin assessment, 5/17/23 nurses' notes entries and 5/17/23 laboratory results. Hourly rounds and daily wander guard safety checks for R#1 were verified via review of the Hourly Elopement Risk Rounding Forms completed from 5/17/23 through 6/11/23. On 6/13/23 at 11:45 a.m. R#1 was observed in the facility walking and redirected when walking towards the doors. (2) LPN AA's suspension and resignation were confirmed via review of the 5/17/23 employee write-up information and Payroll Status Change form that documented LPN AA was removed from payroll on 5/17/23. During an interview on 6/13/23 at 10:20 a.m., the Administrator confirmed that LPN AA resigned on 5/18/23. The Administrator also confirmed that she reported LPN AA to the state nursing board on 5/18/23. CNA BB's suspension, re-education, and written corrective disciplinary action were confirmed via review of the Employee Counseling/Disciplinary Action Notices dated 5/17/23 and 5/24/23 that documented the initial suspension and subsequent written warning. Also verified via review of the education information signed by CNA BB and dated 5/25/23. During an interview on 6/12/23 at 2:24 p.m. CNA BB confirmed the suspension, written warning, and education she received. (3) Verified via review of the elopement risk score sheet lists, that documented elopement risk scores on all residents, on 5/17/23 and 6/7/23. A review of the elopement risk score sheet lists revealed that the initial six residents identified as high risk for elopement on 5/17/23 were R#1, R#2, R#3, R#4, R#5 and R#7. An additional resident, R#6, was also identified as high risk for elopement on 6/7/23. During an interview on 6/12/23 at 2:45 p.m., the DON confirmed the residents identified as being high risk for elopement and stated that monitoring of R#7 stopped because he was no longer high risk, due to a change in condition. R#6 was a new admission on [DATE]. Review of Hourly Elopement Risk Rounding Tools completed from 5/17/23 through 6/11/23 revealed that hourly rounding was being completed on all residents identified as high risk for elopement. During an interview on 6/13/23 at 11:18 a.m. the Administrator confirmed review of the forms. Confirmed through interview with the SSD on 6/12/23 at 12:34 p.m. she completed a 100% audit of all 60 residents and identifying six residents as high-risk for elopement and placed on hourly rounding by nursing staff. (4) Monitoring of the front door was verified via observations on 6/12/23 at 9:30 a.m. and 6/13/23 at 9:05 a.m. of a staff person stationed in the front lobby, monitoring the front door. Also verified via review of the Employee Sitter Logs for the front door from 5/17/23 through 6/12/23. Approval and pending installation of a new wander guard system upgrade was verified via review of the 5/22/23 proposal and 5/25/23 signed approval (by the CEO) and 5/26/23 purchase order for a Rome Alert System. During an interview on 6/13/23 at 11:18 a.m., the Administrator confirmed purchase of the new wander guard system and stated that the equipment had shipped on 6/12/23 and would be installed once received. (5) Verified via review of the LTC Elopement Policy with revision date of 6/2023. The policy included care plan procedures related to elopement. The policy as signed by the facility CEO, Director/VP of LTC, and the LTC Quality Administrator. A typed, signed statement, dated 6/18/23 from the Medical Director confirmed his agreement with the LTC Elopement plan. Also verified via interviews on 6/12/23 at 11:27 a.m. with the MDS Lead, on 6/13/23 at 11:18 a.m. with the Administrator, and on 6/13/23 at 12:20 p.m. with the LTC Quality Administrator. (6) During an interview on 6/12/23 at 11:55 a.m., the RN Quality Nurse (who is also the RN Nurse Educator) verified that the in-service education had been completed with all full-time facility staff (in person and/or over the phone) and that the 18 remaining PRN staff would be in-serviced prior to the next shift worked. Review of the in-service education information and staff signature sheets titled Elopement policy/missing resident education and hourly rounds/documentation (dated 5/17/23), Elopement policy/Missing resident (dated 5/22/23), and Compliance and Ethics, IC P&P, Elopement Policy/IPOC (dated 6/6/23-6/8/23) revealed that 10 RN's, 12 LPN's (including 5 agency LPN's), 25 CNA's (including 5 agency CNA's), 5 dietary staff, 1 materials management staff, 2 maintenance staff, 6 housekeeping staff, 4 therapy staff, 1 SSD, and 1 BOM received the in-service education. Staff interviews conducted on 6/12/23 at 11:10 a.m. with CNA CC, at 11:23 a.m. with the Activities Director, at 11:25 a.m. with CNA EE, at 11:36 a.m. with Rehab Tech FF, at 11:40 a.m. with MDS Coordinator GG, at 11:45 a.m. with RN, Unit Coordinator HH, at 11:52 a.m. with Business Office Manager, at 11:55 a.m. with Infection Control, QAPI Nurse and Education Nurse, at 12:07 p.m. with CNA II, at 12:11 p.m. with LPN JJ, at 12:14 p.m. with Medical Records Director, at 12:17 p.m. with CNA KK, at 12:21 p.m. with LPN LL, at 12:34 with the SSD, at 12:57 p.m. with PTA MM, at 1:00 p.m. with HK/Floor Tech NN, at 1:04 p.m. with RN Weekend Supervisor OO and LPN PP, at 1:06 p.m. with the HK Manager, at 1:10 p.m. with Therapy/Office QQ, at 1:15 p.m. with CNA RR, at 1:23 p.m. with Respiratory Therapist SS, at 1:35 p.m. with Vent Unit Coordinator/RT TT, at 1:52 p.m. with HK UU and Vent Unit RN VV, at 1:55 p.m. with HK/Laundry WW, at 2:00 p.m. with the DM and HK XX, at 2:21 p.m. with Dietary Aide YY, at 2:24 p.m. with CNA BB, at 2:25 p.m. with Dietary ZZ, at 2:45 p.m. with the DON, at 3:03 with HK AAA, at 4:24 p.m. with CNA BBB, at 4:35 p.m. with CNA CCC, at 4:37 p.m. with LPN DDD, on 6/13/23 at 9:20 a.m. with LPN FFF, at 9:27 a.m. with CNA GGG, at 9:30 a.m. and at 10:43 a.m. with the Maintenance Director confirmed they had received in-service training on the Elopement books, Elopement Policy, Elopement resident profiles and care plans. (7) During interviews on 6/12/23 at 11:55 a.m. and 6/13/23 at 11:45 a.m., the RN Quality Nurse confirmed that the facility had no part-time staff and the 18 PRN staff members would be in-serviced prior to the next shift worked. (8) During an interview on 6/13/23 at 11:45 a.m. the RN Quality Nurse confirmed that no new staff shall work without first receiving education on the elopement policy. She stated that the facility did not currently have any newly hired staff. (9) All of interventions were verified via observations, interviews and record reviews previously stated at above at numbers 1-8. (10) During an interview on 6/13/23 at 11:18 a.m., the Administrator confirmed that elopement interventions would continue to be audited and reviewed until 100% compliance is achieved for 6 consecutive months and any deficient practice identified would be addressed with an ADHOC QAPI meeting. During an interview on 6/13/23 at 11:45 a.m., the Quality Nurse also confirmed the continued review of elopement interventions and audits through the QAPI process. She stated that elopement had been added to the list of topics and information to review. (11) All corrective actions were completed on 6/8/2023 and the immediacy of the IJ was removed on 6/9/23.