**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviews the facility failed to prevent a cognitively impaired resident who requires supervision in the community that has a behavior of wandering from leaving the facility unauthorized without staff knowledge. This affected 1 of 3 (R6) residents reviewed for safety, supervision, and elopement. This failure resulted in R6 leaving through his bedroom window without staff knowledge. The Immediate Jeopardy began on 5/7/24. V1 Administrator was notified on 5/16/24 at 12:04PM of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 05/16/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R6's diagnosis, include but are not limited to Encephalopathy, Drug Induced Subacute Dyskinesia, Malaise, Reduced Mobility, Adjustment Disorder, Type 2 Diabetes Mellitus, Seizures, and Hypertension. R6's Cognitive patterns assessment dated [DATE] indicates score of 8. Additionally, R6 displays fluctuating inattention and disorganized thinking. Facility Reported Incident Form titled Initial Report states on 5/4/24 at 4:00PM it was reported to the A. Admin that resident is missing from the facility by the social service staff, green protocol had been initiated and resident was not found in the facility. A review of the Fire Department Run sheet dated 5/7/24, call received at 6:17AM, states R6 arrived ambulatory to the fire station stating he was experiencing double knee pain. Patient transported to the hospital. On 5/7/24 at 2:21 PM R6 said he went to the church, he slept downstairs around the church, in a stairway at the church. R6 said he did not have medicine. R6 said he opened the window and left the facility. R6 said he left when his roommate was sleeping at 7:00 AM, as the sun was rising. R6 said the windows were not supposed to open like that. On 5/9/24 at 10:35AM surveyor met with R6. R6 observed able to stand, turn, and ambulate without assistance. R6 difficult to understand, speech slurred, but some words understandable. R6 said yes he left and he got a ride and then went to the hospital because he was told to go there. R6 asked if he knows his address or the facility address, R6 said no to both. On 5/9/24 at 11:41AM V5, Certified Nursing Assistant (CNA), said on 5/4/24 around 3:00PM the nurse asked me if I had seen R6. V5 said the nurse asked me to look for R6. V5 said I left at 3:00PM and R6 was not found. On 5/9/24 V7, Licensed Practical Nurse, said on 5/4/24 in the afternoon around 2:00 or 2:30PM I did not see R6 in his room. V7 said I raised alarm and asked the CNA about him. V7 said a code purple was initiated. V7 said I notified Social Service Department that I don't see R6. V7 said when I checked R6's room, there was no one in the room, his roommate was in the dining room. V7 said I didn't look at the window. V7 said when I went outside, I saw a footprint on the ground about 2 feet from the window. V7 said at baseline R6 is very sneaky and goes around the facility. V7 said R6 has periods of confusion at times, and he can be hard to redirect due to his confusion. On 5/9/24 at 10:49AM V3, Social Worker, said, no one is a high risk of elopement in the building. V3 said I would know if they are at high risk for elopement. V3 said they have to make an attempt multiple times to exit to place them on high risk for elopement with a monitor. V3 said I was called in Saturday 5/4/24 and I was made aware R6 left. V3 said I came to the facility, and we did a room head count and we drove around the area looking for R6. V3 said R6's baseline behavior is confused, he talks slow, and he speaks loud. On follow up interview on 5/10/24 at 9:31AM V3 said a cognitive (BIMS) score of 8-12 is moderate cognitive impairment. (R6's score is 8). V3 said R6's behaviors include anger and tone changes, he will curse, is socially inappropriate, and uses inappropriate words. V3 said R6 wanders in the facility. At 10:59 V3 said I have to find out what score from the elopement assessment indicates the person is at risk. On 5/9/24 at 11:14AM V4, Social Services, said on 5/4/24 we were searching for R6. V4 said I became aware by the nurse at 3ish (3:00PM), I instantly checked R6's room and toilet, looking for him. V4 said I called a code purple immediately. V4 said when I looked in R6's room I saw the tv remote on the bed, his blankets on the bed, and all his personal possessions still there. V4 said R6 got out thru the window, but it was no longer open. V4 said R6 could open the window enough to get out. V4 said R6's window screen had returned to how it was supposed to be. V4 said R6 did not have an accomplice that I am aware of. V4 said we don't have any high risk elopement residents. V4 said R6's window led outside to the front of the facility. V4 said R6 went without medication while away. V4 said R6 was gone from Saturday 5/4/24 until Tuesday 5/7/24. V4 said according to GPS the hospital where R6 was located is about 6.7miles from here. On 5/9/24 at 12:38PM V6, Maintenance Director, said on Saturday, 5/4/24, I was called in and the Administrator asked me to help with the windows. V6 said I had some corner L shaped brackets here and used some regular screws. V6 said I have the screen for R6's former room in my office. V6 said the screen was on the mulch on the ground when I got here. V6 showed the surveyor the L shaped metal bracket screwed into the windowsill. On 5/10/24 at 12:35PM V6 said on Saturday 5/4/24, about 20 windows didn't have L brackets, none of the outside facing windows had them before I installed them. V6 said all the windows were resident rooms. V6 said the reason I put the bracket is to keep the window from opening so wide, this is a safety mechanism. V6 said before Saturday the windows had nothing in place to prevent them from opening so wide, 49-50 inches. V6 said I do rounds everyday, I check windows, make sure they are not wide open. V6 said I never noticed them to be open so wide. V6 said they should not have them wide open, to prevent this issue from happening again. V6 said I have always checked the windows and I would close them to prevent someone from getting out. V6 said in the past I had seen windows open so wide. V6 said the installed brackets allow the window to open roughly 3-4 inches. V6 said I never mentioned to anyone if I saw a window open wide. V6 said the windows are not new. V6 said I work Monday thru Friday and I check the windows Monday thru Friday. V6 said no one is here over the weekend to do my rounds. V6 said I would hope staff would check the windows. V6 said I don't remember if R6's window was open when I came in Saturday 5/4/24. On 5/10/24 at 10:13AM V2, Director of Nursing, said on 5/4/24 I was notified that code purple was called for R6. V2 said I was not able to come in, but I had phone calls to figure out what was going. V2 said when R6 was found the hospital called and said he was found. V2 said from the phone calls, it was determined that V5 was the last person to see R6 around 1:30PM. V2 said I am not aware what R6 was doing or where he was last seen. V2 said it was determined that R6 got out by the window in his room, because the screen was out. V2 said I would say no for community pass for R6. V2 said R6 gets frustrated and impatient with communication, he is aphasic. V2 said R6's attention span is not focused, his attention and patience is short. V2 said R6 has a psyche background, his thought process can be unorganized. V2 said when R6 returned he look tired. V2 said R6 said he went out the window. V2 said I would describe R6 as a wanderer, he is not typically in one place, you have to look for him. V2 said R6 needs supervision while out of the facility. On 5/10/24 at 11:09AM V12, Assistant Administrator, said I got a call at home around 3ish, that they could not find R6. V12 said I came in to assist with the search. V12 said we could not find R6 in the building or neighborhood. V12 said I looked at the camera footage for the front door and back doors and he was not seen. V12 said there is no front door outside camera. V12 said R6 was last in the facility around 1:30PM. V12 said the CNA reported she last saw R6 at 1:30PM while changing the roommate. V12 said when I came to the facility, we saw the screen in the mulch, and we thought R6 went out the window. V12 said R2 can open the window. V12 said we were notified R6 arrived to the hospital in an ambulance. V12 said when he returned, R6 told me he went to the fire department and was taken to the hospital and that he was tired. V12 said I did not speak with the fire department. V12 said I am not sure which fire department he presented at. V12 said I don't think R6 knows the phone number to the facility. V12 said R2 could not be unsupervised in the community. On 5/10/24 at 11:40AM V1, Administrator, asked for the surveyor to follow her to show me something. V1 escorted the surveyor to R6's room at the time of elopement. V1 said I asked V6 to remove the L bracket so I can show you how R6 got out the window. V1 opened the window fully (as measured before) and climbed one foot on the adjacent bed, stepped onto the window ledge, and jumped down onto the raised landscaped area with mud and mulch. V1 said and V12 found this screen (V6 was replacing the window screen) right here. The surveyor noted the screen frame is bent. On 5/14/24 at 12:46PM V13, Doctor, said if R6's pass states R6 needs supervision while in the community, then R6 should not be in the community unsupervised. R6's Order Summary Report documents may go out on pass with medication with family. R6's progress notes dated 5/4/24 states in part, R6 not in room. Dining room and surrounding areas checked. Social Services immediately notified. R6's progress noted dated 5/7/24 at 10:45AM R6 returned from hospital. R6 Behavior assessment dated [DATE] documents delusions and wandering occurs 1 to 3 days during the assessment period. R6's Elopement Evaluation dated 2/29/24 notes a score of 3. Evaluation includes, the resident has demonstrated or presents with the physical ability to leave the building no. On 5/7/24 R6's score is 19. R6 exhibited elopement behavior has evidence by leaving the facility unauthorized. R6's Community Survival Skills Evaluation dated 2/29/24 states R6 needs supervision to access the community. R6's care plan initiated 4/2/24 states, R6 displays poor boundaries with staff and co-peers as evidenced by his wandering tendencies. R6 has poor perception of personal space. R6 is socially inappropriate towards peers and staff. Interventions include: Encourage resident to participate in groups/activities/events throughout the facility. Redirect resident appropriately when seen displaying inappropriate boundaries. Staff to be consistent with setting limits in order to maintain boundaries. R6's care plan initiated 5/7/24 states R6 had an unauthorized departure from the facility. Interventions include R6 applauded on all progress made towards goal. R6 will be reeducated on supervision policy. Facility provided hospital records dated 5/7/24 at 6:30AM note R6 reason for visit is knee pain. Medications given Ketorolac. The facility elopement guideline dated 9/2023 defines elopement as a situation where a resident who cannot recognize normal dangers and hazards outside the facility leaves the facility without staff knowledge. The survey team confirmed by observation, interview, and record review the immediate Jeopardy was removed on 5/16/24. The Immediate Jeopardy that began on 05/07/24 was removed 05/16/24 when the facility took the following actions to remove the immediacy. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. A. Identification of Residents Affected or Likely to be Affected: -On 5/16/24, nine (9) other residents were identified as wanderers and were added to the elopement list following the completion of the reassessment. - All nine (9) residents were also added to the elopement binder. - The Care plans were reviewed and updated accordingly for all nine (9) residents. Eight (8) of the nine (9) residents were moved to rooms with windows that lead to a courtyard and are not directly accessible to the exterior/exit areas of the facility. One (1) resident refused the room change; however, her room is located directly across from social services office and her windows have been secured. - There is a total of 11 residents on the elopement list/binder as of 5/16/24. - The facility has a total of 81 windows, all 60 windows were secured to only open three (3) inches except for 21 windows. The 21 windows were not secured because they do not lead/have access to exit the premises as they lead to the patio/courtyard which is within the facility. The maintenance director assessed and secured all external windows that are accessible to exit the premises on 5/4/24. - On 5/4/24, the Asst. Administrator initiated an in-service/training on elopement protocol to staff. - The trainings on elopement prevention mentioned in the section (a-h) are new and have been integrated in the facility's policies and procedures regarding elopement prevention. - The facility does not utilize agency staff at this time, nonetheless, if the need arises in the future, the DON/ADON/Charge nurse will provide training on elopement prior to start of shift. 1. On 5/7/24, the IDT (Interdisciplinary Tteam) which includes the DON (Director of Nursing), unit manager, social services director, activity director reviewed R6's care plans to ensure that wandering behavior and elopement risks are addressed. Resident was moved to another room, with window that opens to a secured courtyard. The window was secured so it does not open fully. R6's - elopement assessment was completed by the social services director on 5/7/24. R6 was added to the elopement binder. Nurse Practitioner also completed an evaluation upon return to the facility on 5/7/24. Furthermore, R6 was placed on one-to-one supervision for 72 hours which started on 5/7/24. 2. Resident head count of the whole facility was completed by the DON/clinical managers on 5/16/24. There was no concern identified. Headcount is done during shift change as part of the nurse-to-nurse shift reporting and when completing the midnight census. 3. Elopement/Wandering assessment will be completed for all residents. The assessment will be completed by the DON (Director of Nursing), unit manager, Administrator and Social Services. This will be completed on 5/16/24. 4. Any resident who is identified with wandering behavior/ elopement risk will have care plans developed. This will be completed by the IDT on 5/16/24. 5. The elopement binders will be updated and will have elopement binders in all nursing stations, kitchen, front desk, and department head offices. The elopement binder is not new, but it is updated when a new resident is added to the binder. A resident is added to the binder when the resident is identified with exit-seeking behavior/risk for elopement. 6. The Maintenance Director/Environmental staff will assess all windows of the facility and will secure windows and prevent the windows from fully opening to prevent a resident from using the window to exit the building. The Maintenance Director/MOD (Manager on Duty) will conduct rounds of all windows daily to ensure windows are always secure. The QAPI team conducted an Ad-Hoc QAPI meeting on 5/16/24 and decided to secure the windows to only allow 3-inch opening to prevent a resident from using the window to elope. An Ad-Hoc resident council meeting is scheduled on 5/17/24 to discuss the new standard of securing the windows in the facility. The facility utilized an L-bracket (also called corner brackets or angle braces) which is fastened to the window frame to prevent the window from fully opening and only allow the 3-inch opening. The residents are not able to tamper with the security of the windows. 7. The Administrator will provide training to the IDT regarding development of care plans to address residents who are identified with exit-seeking /wandering behaviors and elopement risk. The training will be completed on 5/16/24. 8. The DON/Administrator/Social Services Director will provide education to the staff on 5/16/24. The education items include but not limited to: a) Code Purple b) Use of the elopement binders c) Exit-seeking behaviors and interventions d) Elopement risk and wandering and interventions e) Policy on missing resident f) Responding to alarms and g) Resident safety and supervision h) Reporting to the Administrator/Maintenance Director any concern related to windows. The training will be completed on 5/16/24. Any staff who are not available, on vacation or leave of absence will have training completed at the start of their shift upon return to work. To measure knowledge retention, posttests will also be started on 5/17/24. The Administrator/Director of Nursing/Social Services Director will conduct posttests of five (5) random staff to evaluate knowledge retention. Five (5) posttests per week for four (4) weeks will be completed, starting on 5/17/24. The acceptable score of the post-test is 100%. Any staff who will not meet the acceptable score will receive additional training. The Administrator/Director of Nursing/Social Services Director will provide the staff with training on specific areas based on the results of the post tests. To ensure that all staff are trained prior to the start of their next shift if off duty, the DON/Administrator will notify the staff to meet with their supervisor/charge nurse/DON when they return to work. The supervisor/charge nurse/DON will ensure that the training is done before starting their work shift. The Administrator/DON/Social Services Director will provide the training. If the DON/Social Services Director are not available, a trained nurse will provide the training. The facility will conduct the same training quarterly for four (4) quarters, and then annually thereafter. The training will also be included in the orientation of new employees. At this time, the facility is not utilizing agency. In the future, if the facility will use agency, the DON/Social Services Director/Administrator will provide the same training to the agency staff. B. Actions to Prevent Occurrence/Recurrence: 1. Ad-Hoc QAPI meeting was completed on 5/16/24 which were participated by the leadership team which includes the Director of Nursing (DON), Unit Manager (UM), Risk Manager (RM), Social services Director (SSD), Admissions Director, Minimum Data Set (MDS) Coordinators, Maintenance Director, Business office Manager (BOM), Rehabilitation Manager, Human Resource Director and the Activities Director (AD). The Medical Director also participated via telephone. The QAPI team discussed the incident and the corrective actions to prevent similar events. 2. Elopement drill will be completed on 5/16/24 by the Maintenance Director and Administrator. This will also be completed daily, for the seven (7) days, and will be done at different shifts. After seven (7) days, the elopement drills will be done weekly for three (3) months, then monthly thereafter. The elopement drills will be completed per policy, as indicated above. 3. All exit doors in the facility will also be checked by the Maintenance Director on 5/16/24 to ensure all doors were locked and secure and that delayed egress was functioning properly. Door checks will be completed daily, including weekends by the MOD-manager on duty/charge nurse. The door checks will be completed by Maintenance Director, or other members of the maintenance team. If there is any concern identified, the Administrator and/or the Maintenance Director will be notified immediately. If there is any concern with the door, a staff member will be assigned as door monitor until the door concern is addressed. The Maintenance Director/Environmental Service Director/MOD will also conduct window checks daily. Window checks will be completed daily, including weekends by the MOD-manager on duty/charge nurse. The window checks will be completed by Maintenance Director, or other members of the maintenance team. If there is any concern identified, the Administrator and/or the Maintenance Director will be notified immediately. If there is any concern with the door, a staff member will be assigned as door monitor until the door concern is addressed. 4. Daily, the DON, clinical managers, and members of the IDT will hold clinical meetings and discuss new or worsening wandering/ exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring that appropriate clinical interventions are implemented to prevent an incident of elopement. The MOD (manager on duty)/charge nurse, DON will also conduct weekend clinical meetings to review new or worsening exit seeking/wandering behaviors and ensure interventions are in place to prevent elopement. 5. New admissions will be reviewed by the DON, Risk Manager, Wound Nurse or MDS for elopement risk and any resident identified as being at risk will be updated into the facility elopement books. 6. The QAPI team will hold a weekly Ad-Hic QAPI meeting to discuss the elopement prevention program and review interventions to new/worsening wandering/exit-seeking behaviors. The QAPI team will determine if additional corrective actions are necessary based on concerns identified. The Administrator/Social Services Director/DON will conduct audits of the Elopement Binder daily for three (3) months to ensure that identified elopement risk are included in the binder. Additionally, the Administrator/Social Services Director/DON will also review five (5) residents weekly for three (3) months to ensure that residents who are identified with new and/or worsening exit-seeking behaviors and wandering are being addressed in the care plans. After three (3) months, the QAPI team will determine if additional monitoring or corrective actions are necessary. To evaluate the effectiveness of the removal plan, QAPI team will review results of the audits, posttests, door and window checks. The QAPI team will determine if additional monitoring or corrective actions are necessary based on the review of monitoring activities.