**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure supervision of a moderately cognitively impaired resident with a history of diabetes, mental illness, illicit drug use, and new onset aphasia; and failed to follow the facility elopement policy resulting in a delay in contacting the police for approximately 20 hours after the resident had gone missing for 1 of 4 residents reviewed for quality of care (Resident B). The immediate jeopardy begun on 3/30/23 at 8:30 p.m., after Resident B was witnessed by her peers to be upset and tearful and left the facility without signing out as she usually did. Staff became aware Resident B was missing at approximately 8:30 p.m. when she was unable to be located for her evening medication administration. Although an initial search was conducted by nursing and administrative staff, the search was stopped at 11:45 p.m. without locating the resident. Law enforcement was not notified until 3/31/23 at 4:22 p.m., approximately 20 hours after Resident B went missing. Ultimately, a body presumed by law enforcement to be Resident B was later found on 4/17/23 less than half a mile from the facility. The [NAME] President of Risk Management and Performance Improvement (VP, RM-PI), Regional Director of Clinical Operations (RDCO), Administrator (ADM), and the Director of Nursing (DON), were notified of the immediate jeopardy on 4/28/23 at 5:01 p.m. The immediate jeopardy was removed, and the deficient practice corrected, on 3/31/23, prior to the start of the survey and was therefore Past Noncompliance. Findings include: During a confidential interview with one of Resident B's peers, it was indicated Resident B had been upset in the days leading up to her elopement. She had recently had a stroke and could no longer talk except for repeating the word, well, over and over. The peer indicated they were with her on the smoking patio the night of 3/30/23 when she left the facility. She had been very upset, inconsolable, and cried. The peer was unable to determine why she was upset because all she could say was, well, well, well, well. Resident B did not want to go back inside when the peer did, but the peer told a nurse that Resident B was still upset and outside crying. During a confidential interview with another of Resident B's peers, it was indicated Resident B was on the smoking patio the evening of 3/30/23 and was uncontrollably crying. The peer was not able to understand Resident B because she could only repeat the words, Well, well, well. When the peer was done smoking, they tried to get Resident B to come inside with them, but she was not done with her cigarette yet. It was getting dark, and it was cold. She was still crying. The peer was worried about Resident B so when they went back inside they told one of the nurses that Resident B was still outside in the smoking area, upset and crying. During a confidential interview with a third peer, it was indicated Resident B was very different after her stroke. She was mad and frustrated about everything that happened, and could only repeat, well, well, well, well. She got stuck on that word and it made her so mad she would start to cry. There was a rumor that her son had been in trouble with the law, and the peer thought maybe she was upset about that. The peer indicated, Resident B would go out LOA all the time, but was always back by midnight. During a confidential interview, a peer who had been one of Resident B's roommates indicated it was obvious that Resident B was different after her stroke, she could not talk anymore which made her angry and upset, she screamed and cried a lot more after the stroke. During a confidential interview, one of Resident B's peers indicated, they were in their room which had a window that overlooked the smoking patio. They observed Resident B outside with two peers on the evening of 3/30/23, and Resident B was clearly upset. When the two other peers came back inside, they decided to go outside and smoke one more time before night. In a span of 15 seconds, with their back turned to get an E-cigarette, Resident B was there, and then gone. She had a red walker. During a confidential interview with a family member, it was indicated, Resident B was trying to get better so she could leave the facility and live on her own again. Before she had the stroke, she complained that she did not receive her insulin, but after her stroke all she could say was, well, well, well. The family member worried about how the resident would communicate and staff would understand if the resident needed something or missed more of her insulin. After Resident B's body was found, the family was told she left the facility because she wanted to leave. But she did not take her identification (ID), phone, wallet, bus pass, or other items she would need or that she would always take with her when she went on Leave of Absence (LOA). The family member indicated Resident B had a history of mental illness which included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and was impulsive. Along with her mental illness she had used illicit drugs in the past to cope, and because of her history and behaviors she needed additional supervision and help with her medical management. This was why she was in a nursing home in the first place. During a confidential interview with a family member, it was indicated, they got a call around 9:00 p.m., on the evening of 3/30/23. It was a nurse from the facility asking the family member if they had heard from or knew where Resident B was. The family member indicated, no, they had not, and asked what was wrong. The family member was told Resident B had left the facility and not returned yet. They told the family member not to worry and they would call back with an update, but never did. The family member never knew Resident B was missing or potentially in danger until a detective called them on 4/20/23. The detective told her they found a body with similar characteristics as Resident B. Until DNA could confirm the identity of the deceased , it was assumed to be Resident B due to identification makers of surgically amputated toes, and a unique tattoo on her back. The family member indicated they were shocked and angry because the family was never called back with an update from the facility when she did not return to the facility the next day. If they had been notified, the family member would have come to help with the search. During a confidential interview, a staff member indicated Resident B had been at the facility for close to a year. She had been pleasant and engaged with other residents before her stroke. After her stroke she kept more to herself and was unable to talk with her friends anymore which made her upset. Resident B was a bad diabetic, her sugar would drop all the time. Half the time she would eat, but other times she would not. Although Resident B had a bit of a past, and had used Meth and other drugs, since being at the facility she was clean and worked hard to get better so she could leave. Resident B was a resident that smoked, she knew the code to the smoking patio, which was the same as the front door code, so she could leave anytime she wanted. She would occasionally forget to sign out, but most of the time she did use the LOA book and signed herself in and out. After her stroke, maybe she had more difficulty remembering to do that. It was indicated the staff member knew Resident B very well, and she never heard her make statements that she was going to leave. She did go out of the facility a lot, but she always came back by midnight. During an interview on 4/27/23 at 1:00 p.m., Unit Manager (UM) 16 indicated Resident B was friendly and outgoing. She liked to socialize with the other residents, mostly the other smokers, and she would go to the smoking patio a lot. Since Resident B was an independent smoker, she was able to take herself in and out for smoke breaks, but the policy of the facility was no smoking between the hours of 10:00 p.m. and 6:00 a.m., for resident safety. After her stroke she remained independent with her smoking and was compliant with the smoking policies. On the night of 3/30/23 UM 16 got a call from the DON around 10:00 p.m., who asked her to come to the facility and help find Resident B. UM 16 arrived to the facility around 10:15 p.m., and begun to assist in a search for Resident B. A resident count was completed, and the entire facility was searched. Additionally, UM 16 and the Scheduler got in their vehicles and drove through some surrounding neighborhoods. They were unable to locate Resident B. Around 11:45 p.m., the search concluded, and staff were dismissed to go home. During an interview on 4/27/23 at 2:16 p.m., the Scheduler indicated Resident B enjoyed being outside with her friends and smoked quite a bit. In the days leading up to 3/30/23, she had been her normal self until the day before or the day of when she had been upset over some news regarding her son. On the evening of the 30th, she got a call from the DON to come assist with the search, but they were unable to find Resident B. Around 11:30 to 11:45 p.m., they stopped searching and were told to go home. During an interview on 4/27/23 at 2:20 p.m., the DON indicated she was hands on with the residents of the facility and knew Resident B well. Resident B was an independent smoker and compliant with the facility's policy. Resident B did have the code to the smoking patio, which was the same as the front door, and it was common for her to leave LOA for hours and sometimes days at a time. Resident B also utilized the LOA book to sign herself out, but sometimes she forgot. During an interview on 4/27/23 at 2:39 p.m., Registered Nurse (RN) 21 indicated she was the nurse working on the evening of 3/30/23. She did not notice Resident B was gone until she went to her room to give her evening medication between 8:00 and 9:00 p.m. She looked around but could not find Resident B, so she asked some other staff to help her. When they were unable to locate Resident B she called the DON. RN 21 indicated Resident B sometimes forgot to sign herself out LOA, so they thought that was what happened that night. During an interview on 4/27/23 at 3:30 p.m., the ADM indicated she received a call around 9:30 p.m. on 3/30/23. She was notified that staff were unable to locate Resident B. She rushed to the facility. During the drive in the ADM made a call to her supervisor and the RDCO and VP-RM/IP. When she got to the building, all staff conducted what she called a Fire Watch, wherein every door in the facility was opened. A resident count and search of the grounds was conducted. Some staff members even went in their own cars to look for her in the surrounding neighborhoods. The ADM tried to call Resident B since she was her own representative, but Resident B did not answer. When the ADM looked in Resident B's room, they did not find her phone, but did find her wallet with her ID. The search was concluded around 11:30 or 11:45 p.m. as the staff assumed she must have gone LOA and forgot to sign out. She probably walked to a friend's house. The ADM returned early the next morning and learned Resident B still had not returned, which was when they decided to contact the police. The ADM indicated the police came and took a statement, but they did not search her room of the facility/grounds, they did not ask for specific medical conditions, or request a recent photo of Resident B. The ADM printed off Resident B's face sheet and provided a copy to the officer. During an interview on 4/28/23 at 12:01 p.m., the facility's attending Psychiatrist indicated, He knew of Resident B from a previous stay in another nursing home and found her to be unreceptive to psychiatric care, she was not very open. After Resident B admitted to the current facility, he saw her twice before she left. An initial face-to-face visit and assessment was conducted on 2/15/23 and he determined psychiatric services were needed due to her bipolar disorder and polysubstance abuse. In his opinion and professional judgement, Resident B needed a mood-stabilizing medication, in the worst way, but Resident B was unaccepting of his recommendation. When asked if Resident B exhibited behaviors related to her bipolar disorder he indicated, Constantly! She had no impulse control; her mood swings were erratic. She was going to do something stupid. When asked if her behaviors were problematic enough to require increased supervision and medical management, he indicated, of course she needs more supervision that's why she's there, she's a mess. When asked if Resident B would be considered cognitively impaired, he indicated, it was difficult to determine as a comprehensive cognitive exam of her baseline status due to her refusal to answer questions and non-compliance with a medication regimen. He indicated the notes he documented for her were rather short and general due to the fact she was unreceptive to the service. During an interview on 4/28/23 at 1:40 p.m., Occupational Therapist (OT) 23 indicated she had conducted Resident B's initial OT assessment when she returned after her stroke on 3/16/23. At that point, in the first several days after her return, she was very impulsive and could only say, well, well, well. She would forget to lock her wheelchair breaks when she stood up, forget to use her walker, and needed a lot of reminders to slow down. During an interview on 4/28/23 at 1:55 p.m., Physical Therapist (PT) 24 indicate Resident B had a distinct and significant decline in her physical and cognitive function after her stroke. Before she had been nearly independent with all her ADLs (activities of daily living) but after her stoke she needed a lot more assistance and could only repeat the word, well. She had poor safety awareness and was impulsive which increased her risk for accidents. She would get very frustrated when she could not communicate, I could see it on her face, and she would cry. During an interview on 4/28/23 at 2:35 p.m. the Detective assigned to Resident B's case, indicated the investigation was ongoing and although they were waiting for DNA conformation, the body found near the facility was very similar to the missing person reported from the facility. The detective indicated a walker was located approximately 1600 feet away from the facility, and the body was located approximately 1000 feet from the walker. It was assumed that she had been wearing shoes, but only one tennis shoe was found, and she only wore a t-shirt with a pair of black sweatpants type pants. The detective indicated the missing person report was filed on 3/31/23 at 4:22 p.m. During an interview on 4/28/23 at 2:52 p.m., the ADM indicated the facility's elopement procedure was to first determine if the resident had eloped or was gone LOA. An elopement was any resident that was not cognitively intact, or confused, and left without signing LOA. At the time, the ADM and her supporting staff, did not consider Resident B as eloped because she often left LOA without signing out. The only reason they had decided to do a search for her was because of her history of drug abuse. They did not consider her a missing person until she had not returned the next day. On 4/27/23 at 11:25 a.m., Resident B's medical record was reviewed. She had diagnoses which included, but were not limited to, type II diabetes (a blood sugar disorder) with neuropathy (numbness, tingling and/or pain in the extremities and hyperglycemia (high blood sugar), other stimulant abuse, severe and reoccurring major depressive disorder. A quarterly Minimum Data Set (MDS) assessment, dated 1/16/23, indicated Resident B was moderately cognitively impaired with a BIMS score of 12. She was admitted on [DATE] after an acute hospital stay in which she was treated for severe burns to her toes. They became infected and required amputation. She re-admitted to the facility on [DATE]. A Pre-admission Screen and Resident Review (PASRR), dated 12/5/22, indicated Resident B was considered mentally ill and met PASRR criteria with the diagnoses of bipolar disorder and schizophrenia. A nursing progress note, dated 1/18/23 at 2:14 p.m., indicated Resident B called a cab to be picked up and was going to stay with her daughter. She had signed the LOA book. The corresponding pages from Resident B's LOA book indicated she had signed herself out on 1/18/23 at 12:13 p.m. The time planned to return was after a few hours, but the return date and time were left blank. The record lacked documentation of when Resident B returned. The next nursing progress note in Resident B's file was not until 1/20/23 at 3:00 p.m., which was a change of condition notification due to the resident's unusual behavior. A corresponding Nurse Practitioner, (NP) note, dated 1/20/23 at 4:29 p.m., indicated the NP had been in to see Resident B for a follow up to her toe amputation but was found sitting on the floor of her room wearing only a bra. She was observed to have uncontrolled gross motor clonic-type (repeated/violent muscle spasms) movements of arms and legs. She had a drug pipe in between her breasts that fell out of the bra when she rolled over. She was observed to have uncontrolled tongue thrusting, erratic speech and behaviors. She was resistive to staff care and admitted to using Meth. The NP gave an order to send the resident to the hospital due to stimulant intoxication for detox. Resident B's sign-out log was reviewed between the dates of 12/1/22-3/24/23. The log indicated Resident B's compliance with the LOA policy as it was evident, she consistently signed herself out, at least several times a month, even after her stroke. The record lacked however, any documentation of her inability and/or refusals to follow LOA policy. Resident B's comprehensive care plan was reviewed and although Resident B's history of illicit drug use was well known, and stimulant abuse was one of her admitting diagnoses in April 2022, care plans for substance abuse were not initiated until January 2023. A care plan, initiated 1/3/23 indicated Resident B had a substance use disorder disease process related to use of Meth and was at risk for complications. An intervention added to the plan of care after she returned on 1/23/23 was a referral to a substance abuse treatment facility to which Resident B was willing to do. The Social Service Director (SSD) placed a referral to a local facility who would have a bed available on 1/25/23, however on 1/24/23 the treatment center called the SSD back and indicated at that time Resident B was too medically complex for their program. A second care plan initiated 1/20/23 indicated Resident B had substance abuse behavior. Interventions for the plan of care included 1:1 supervision. An Interdisciplinary Team (IDT) progress note, dated 2/6/23 at 9:49 a.m., indicated Resident B was removed from one on one (1:1) supervision, however the care plan was not revised to remove the 1:1 supervision and a new intervention in its place was not added. A change of condition nursing progress note, dated 3/12/23 at 3:38 p.m., indicated Resident B had experienced an acute change of condition as evident by .Resident observed with slurred speech et mumbling, drooping right side of face, weak right arm/hand A nursing progress note, dated 3/13/23 at 6:13 a.m., indicated Resident B was admitted to the hospital after a stroke and new diagnosis of expressive aphasia. An admission nursing assessment was completed on 3/16/23 at 7:16 p.m. and indicated Resident B's cognitive status was not assessed due to aphasia. A brief smoking and elopement sections were included as a part of the overall admission assessment and had not changed since her last assessment. Further, a PTSD (post-traumatic stress disorder) screening asked if the resident had a history of drug use which was selected yes, but the type of drug used and dated of last use were not recorded, (admitted Meth use and transfer to the hospital on 1/20/23 for detox). The admission assessment's psychological assessment was detailed, depressed of her situation. A full hospital discharge summary note, dated 3/16/23 at 2:39 p.m., indicated Resident B had been admitted to the hospital and diagnosed with an acute CVA, expressive aphasia, receptive aphasia and a new diagnosis of PFO (patent foramen ovale- a hole between the left and right atria (upper chambers) of the heart, which increased the risk of stroke). Upon her readmission, Resident B was assessed and placed on Speech Therapy (ST), Occupational Therapy (OT), and Physical Therapy (PT). The corresponding notes were reviewed and revealed the following: Speech Therapy treatment notes as follows: On 3/14/23 at 12:20 p.m., .patient remains aphasic and only answers with well. Patient was able to follow basic commands of sit up and squeeze fingers. Attempted yes/no and picture identification for communication board, patient responses are 50% . do not feel patient has the receptive ability to use communication board at this time On 3/15/23 at 11:22 a.m., .patient remains aphasic . patient more frustrated today and was able to say, oh man. Patient completed yes/no questions with 20% accuracy today On 3/16/23 at 3:10 p.m., .patient declined sitting on the edge of the bed. Patient was able to sequence task of brushing hair and washing face with no cues. Cardiology entered room and patient was able to follow the commands given from the Dr with no cues. Patient then became very tearful and covered her face The ST evaluation and additional analysis, dated 3/23/23, indicated, patient returned from hospital with diagnoses of acute CVA, receptive and expressive aphasia. Attempted to administer BIMS [a test to determine cognitive status] and portions of the SLUMS [another test to determine cognitive status] however patients expressive language disorder impeded participation. Informal assessment of receptive/expressive language abilities indicated that patient responds to yes/no questions with 80% accuracy, follows 1-step directions with 25% accuracy, identifies basic nouns in pictures given a verbal prompt with 60% accuracy, identified numbers with 100% accuracy and identified 1 letter out of 5 prompts . When prompted to write her own name, she wrote number 1-3. Patient attempted to name pictures and engage in conversation; however, the majority of speech output was, well repeated over and over with conversational intonation and gestures. Patient demonstrates limited awareness of this phenomena during conversation; however, she was aware of difficulty with structured tasks as evidence by increased frustration, teary eyes, and refusals A ST daily note, dated, 3/21/23 indicated, .patient was able to identify numbers five a field of 10, however was unable to identify pictures of functional needs . she was able to repeat nouns when given verbal models and picture stimulus cars with less than 25% accuracy. Words observed include, well, no, mmhmm, okay, three and four. A ST daily note, dated, 3/22/23 indicated, .patient observed with lunch tray for 10 minutes. Patient demonstrated an increase in mastication [chewing food enough to be able to swallow]. Patient requires cues to swallow before and after a liquid wash . SLP [speech language pathologist] recommends diet order for mechanical soft with thin liquids and discussed with staff . patient attempts to participate in simple conversation but responds with well well, or oh my. SLP provided simple one step directions. Patient unable to independently complete at this time A ST daily note, dated, 3/24/23 indicated, .SLP educated patient about communication board. SLP provides visual models for three images that are going to be targeted. SLP prompts patient to identify pictures. Patient demonstrates difficulty with comprehension, so SLP attempts to provide hand over hand assistance. Patient is resistant. Patient has difficulty following one-step directions A ST daily note, dated, 3/28/23 indicated, .SLP educates patient about using picture communication board to increase communication skills with staff. Patient demonstrates difficulty with comprehension . Patient demonstrated severe receptive language deficits at this time. Patient becomes emotional because she is unable to communicate with others . A ST daily note, dated, 3/30/23 indicated, .patient is education about picture communication board. Patient is not able to identify any images when prompted . SLP provides visual models and verbal cues. Patient demonstrated decreased activity participation . patient demonstrated difficulty following simple one step directions on the tablet The OT initial assessment and evaluation, dated 3/17/23, indicated, .patient is easily distracted, requires consistent instruction, requires consistent supervision and impulsive. Patient was walking around her room naked upon entering the room to complete the evaluation. Patient answers all questions and speech consists of well well well only . patient presents with a significant change in status from her prior level of functioning due to recent CVA with subsequent weakness and expressive/receptive aphasia . she was highly impulsive during ADL and transfers completion and was attempting to walk around her room without and clothing . risk factors: due to the documented impairments and associated functional deficits, the patient is at risk for compromised general health, decreased ability to return to prior level of supervision, decreased level of mobility, decreased leisure task participation, decreased participation with functional tasks, falls, further decline in function, increased dependency upon caregivers and muscle atrophy An OT daily note, dated, 3/30/23 indicated, .patient safety awareness is fair, but she is impulsive and needs almost constant reminders to perform tasks without rushing The PT initial assessment and current referral narrative, dated 3/17/23, indicated .patient referred to PT due to new onset of decrease in strength decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate, reduced balance, reduced functional activity tolerance, decreased coordination, decreased motor control, cognitive deficits and an increased need for assistance from others placing patient at risk for contractures, decreased ability to return to prior level of assistance depression and falls . at this time of evaluation, patient presents with cognitive decline, aphasia, right facial droop right sided weakness and pain but is unable to rate and locate pain (due to aphasia). Patient also exhibits weakness deficits in right lower extremity coordination, reduced work tolerance and decreased safety awareness resulting in an increased risk for falls and increased dependence from others for functional gait and mobility A PT daily note, dated, 3/23/23 indicated, . patient demonstrates decreased safety awareness at this time . A PT daily note, dated, 3/24/23 indicated, . patient able to follow [cuing] but struggles with impulsivity which limits her safety ' A PT daily note, dated, 3/27/23 indicated, .patient has cognitive deficit (aphasia), is impulsive and had decreased safety awareness at this time. Patient's cognitive deficit is a big barrier to progress in therapy When Resident B was noted missing on 3/30/23 she was unable to receive the following medications which increased the risk of accidents putting her in immediate danger. a. Glargine Insulin, pen-injector 100 unit/mL Inject 55 units subcutaneously (under the skin) at bedtime for Type 2 diabetes mellitus (adult-onset blood sugar disorder) to stabilize her blood sugar and prevent complications of hyper/hypoglycemia. b. Buspirone (anti-anxiety) oral tablet, 15 mg. Give 1 tablet by mouth three times a day for to stabilize and maintain her mental/mood status. c. Quetiapine fumarate (anti-psychotic), oral tablet 25 mg. Give 0.5 tablet by mouth at bedtime to stabilize and maintain her mental/mood status. d. Clonidine (anti-hypertensive) oral tablet 0.1 mg. Give 1 tablet by mouth and at bedtime for hypertension (high blood pressure) to help stabilize her blood pressure. e. Apixaban (to prevent strokes or blood clots), oral tablet 5 mg. Give 1 tablet by mouth and at bedtime for circulation issues. f. FreeStyle Libre Reader Device (continuous blood glucose system receiver). Apply 1 application transdermal (through the skin) at bedtime for diabetes, to stabilize her blood sugar. Additional medications she missed the morning on 3/31/23 included: a. Lispro Insulin, injection solution 100 unit/mL Inject 20 unit subcutaneously with meals for diabetes mellitus. b. Buspirone oral tablet, 15 mg. Give 1 tablet by mouth three times a day for mental/mood status. c. Quetiapine fumarate, oral tablet 25 mg. Give 0.5 tablet by mouth every morning for mental/mood status. d. Clonidine, oral tablet 0.1 mg. Give 1 tablet by mouth every morning for hypertension (high blood pressure). e. Apixaban, oral tablet 5 mg. Give 1 tablet by mouth every morning for circulation issues. f. Paroxetine (treats depression, anxiety, obsessive-compulsive (OCD), oral tablet 20 mg. Give 1 tablet by mouth in the morning for depression. According to the National Weather Service, on 3/31/23, the day after the resident went missing, the local surrounding area experienced severe weather.thunderstorms developed along and ahead of a strong cold front on the evening of March 31, 2023. These storms produced 10 tornadoes along with widespread wind damage. Some fatalities were reported along with multiple injuries. This was part of a larger outbreak that produced a total of 23 tornadoes in Indiana alone. This makes the event the fifth largest tornado outbreak in Indiana history Additionally, weather archives for the night of the 3/30/23, and into 3/31/23 detailed dropping temperatures into the 50's, increased cloud coverage, wind and rain as severe weather moved into the area. By 9:00 p.m., on the 3/31/23 wind gusts as high at 52 miles per hour were recorded. On 2/27/23 at 2:04 p.m., the RDCO provided a copy of current, but undated, facility policy titled, Resident Leave of Absence. The policy indicated, .definition: Leave of Absence/LOA: leaving the facility with the appropriate authorization and notification to do so. Policy: . a resident/patient who is cognitively intact with independent decision making with a physician's order may sign themselves out for a LOA. In the event the resident/patient exits the facility without signing out on the log, the facility will initiate an investigation in an attempt to locate the resident. Upon the resident/patient return to the facility, appropriate re-education for the leave of absence will be completed On 2/27/23 at 2:04 p.m., the RDCO provided a copy of current, but undated, facility policy titled, Elopement Prevention and Management Overview. The policy indicated, .definition: Elopement is defined as when a resident/patient leaves the premises or safe area without authorization and/or any necessary supervision and places the resident/patient at harm or injury . Procedure: . 2. Determine elopement risk factors which may include, but are not limited to: a. Acute or chronic confusion/disorientation, b. Anxiety . e. new admission with adjustment difficulties, or a desire to return to previous living situation On 2/27/23 at 2:04 p.m., the RDCO provided a copy of current, but undated, facility policy titled, Elopement Preven[TRUNCATED]