**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, primary physician and staff interviews, the facility failed to ensure residents were given medications as prescribed by the physician, when a nurse administered the wrong medications to the wrong resident for 1 of 1 residents reviewed (Resident #52). The facility reported a census of 52 residents. Findings Include: The admission Minimum Data Set (MDS) for Resident #52 dated 10/18/23 documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition for decision making. The MDS revealed he had diagnoses of atrial fibrillation, gastroesophageal reflux disease (GERD), arthritis, compression fracture, and neoplasm of the prostate. The resident received an anticoagulant, diuretic and opioid during the 7-day observation period. The Care Plan initiated 10/12/23 directed staff to medicate Resident #52 as directed by the doctor. Review of Resident #52's Medication Administration Record (MAR) dated October 2023, the resident received his morning medications on 10/31/23 as ordered by the physician by Staff K, Licensed Practical Nurse (LPN). The medications included: a. Calcitonin (Salmon) Nasal Solution - 1 spray alternating nostril one time a day. b. Lidocaine External Patch 4% - apply to lower back topically 2 times a day. c. Miralax Oral Powder 17 grams(gm)/scoop - give 1 scoop by mouth to times a day. d. Spironolactone oral tablet 25 milligrams (mg) - give 1 tablet by mouth 2 times a day. e. Acetaminophen - give 650 mg by mouth 3 times a day. f. Baclofen oral tablet 10 mg - give 1 tablet by mouth 4 times a day. Per the facility Incident Report dated 10/31/23 at 8:00 AM, the wrong medication was administered to the wrong resident. Staff C, Registered Nurse (RN) completed the Incident Report. She indicated on the report that she went to the dining room to give resident #50 his 4 medications that she could not find earlier. Resident #50 appeared to be sitting in his regular spot and had his hat pulled down low over his eyes. She told him she had his medications and administered them to him. He then opened his eyes and Staff C realized it wasn't Resident #50 but instead was Resident #52. She immediately found the Director of Nursing (DON) and advised her of the medication error. The physician was notified by Staff C, and Staff K notified the family. The Incident Report indicated the error resulted in the need for the resident to be transported to the emergency room (ER). Recommendations to prevent further reoccurrence noted on the report were to look at the resident's full face and relax. The incident description indicated Resident #52 received Resident #50's pills by mistake. Resident #52 received metoprolol 25 mg, Lasix 40 mg, spironolactone 25 mg, and Risperdal 2.0 mg. The Incident Report indicated Resident #52 was seated in the dining room where Resident #50 normally sits and was slumped like Resident #50 and had a hat on. Staff C, stated she said his name and gave him the medication and as he was swallowing she saw he did not have a mustache and that it was Resident #52. No injuries observed at the time. Per Resident #52's Progress Note dated 10/31/23 at 8:00 AM, the resident had a medication error this morning. The resident was currently in the dining room eating breakfast. His vital signs were as follows: temperature of 97.5 Fahrenheit (F), pulse of 76 beats per minute, respirations were 20 per minute and his blood pressure was 110/50. The resident's oxygen saturation was 96% on room air. The resident denies pain at this time. The DON was made aware of the situation. The resident finished breakfast and is being taken back to his room. Per Resident #52's Progress Note dated 10/31/23 at 8:12 AM, the resident's primary physician was notified of the medication error. An order was received to send resident to the ER for evaluation and treatment due to medications that resident was given. The physician wanted the resident to be monitored. Per Resident #52's Progress Note dated 10/31/23 at 8:25 AM, the ER Nurse was a given nurse to nurse report and 911 was called. Staff H, LPN notified the resident's family at this time. A bed hold was signed by the resident and hospital transfer paperwork prepared. The resident is in his room resting in his recliner and is aware of the situation. Denies pain at this time. Heart rate is regular and strong. No chest pains. Lungs clear bilaterally. No cough or shortness of breath noted. Per Resident #52's Progress Note dated 10/31/23 at 8:44 AM, the Emergency Medical Service (EMS) from the local hospital is in the room with the resident. Paper work given to the EMS staff. Resident left the facility with EMS. Per Resident #52's Progress Note dated 10/31/23 at 1:13 PM, the Social Worker from the hospital called with an update on the resident. He is being monitored and will be returning to the facility after 2:00 PM today. Nurse is to call with a nurse to nurse report. In an interview on 10/31/23 at 1:57 PM, the Administrator approached writer to inform her there had been a medication error this morning and they had sent the resident out to the hospital ER per Physician Order to be monitored. She reported the hospital called and said the resident would be returning today after 2 PM and they had reported the incident to the Department of Inspections, Appeals and Licensing. She did not feel this error was a reportable incident as the resident only needed monitoring. Per Resident #52 Progress Note dated 10/31/23 at 2:51 PM, the resident returned to the facility at this time via facility transportation. Per Resident #52's Progress Note dated 10/31/23 at 2:58 PM, per Hospital Discharge Orders: a. Hold the second dose of spironolactone today. Resume normal medications tomorrow. b. Orthostatic precautions/fall risk for 2 days (10/31/23 - 11/1/23) using extra precautions with transfers. The resident is aware of these orders and the MAR was updated at this time. Per Resident #52's Progress Note dated 10/31/23 at 4:38 PM, the resident reports double vision and lightheadedness at this time. Vital signs were as follows: temperature of 97.4 F., Respiration of 16 per minute, pulse of 82 to 100 beats per minute, and blood pressure of 143/80. Telephone call placed to the physician at this time. Order received for vital signs hourly until 6 AM. Continue to monitor. Treatment Administration Record (TAR) updated and resident made aware. Per Resident #52's Progress Note dated 10/31/23 at 8:07 PM, the resident has been resting in his recliner this evening. Awakens easily. Voices that he had a very busy day with having to go out to the hospital. He denies having a headache, dizziness, light-headedness, or double vision. He voices that has all gone away. His speech is clear and he is alert and oriented. Vital signs are stable with no irregularities noted. He ate his supper and took all of his medications without an issues. Per the Hospital After Visit Summary dated 10/31/23, the reason for the ER visit was accidental drug ingestion, initial encounter. Medications given were Acetaminophen 1000 mg at 12:15 PM and Sodium Chloride 1000 milliliter (ml) intravenous which was stopped at 11:43 AM. Vital Signs at discharge were: Temperature of 96.3 F, Pulse 82 beats per minute, respirations 15 per minute, blood pressure 144/78 and oxygen saturation 99% on room air. Orders included: a. Hold the second dose of spironolactone today. Resume normal medications tomorrow. b. Orthostatic precautions/fall risk for 2 days (today and tomorrow) use extra caution with transfers. ER Course on 10/31/23 included the following: a. At 9:05 AM - 12 lead Electrocardiogram (EKG) shows atrial fibrillation. No significant changes when compared to 3/3/23. b. At 10:11 AM - Potassium level of 4.2 (normal is 3.6 to 5.2), INR (international normalized ratio) (measurement of blood coagulation) of 2.7 (therapeutic range is 2.0-3.0). Will observe for hypotension, bradyarrhythmia until 2 PM. c. At 10:37 AM - Blood pressure 80/65. Sleeping in bed. Soft pressures are noted. No tachycardia but the beta-blocker would prevent that so we will give a liter of fluid and continue to observe. d. At 11:11 AM - Blood pressure 96/57. e. At 11:31 AM - Blood pressure 128/103. f. At 12:40 PM - Made a Mandatory Repot to the Department of Inspections, Appeals and Licensing regarding the accidental administration of another resident's medications to this resident at the nursing home. g. At 1:43 PM - Blood pressure 144/78, pulse 70-100 beats per minute in atrial fibrillation. He ate lunch, alert and wake indicating that he feels fine. Poison control recommended 6 hours tele-monitoring so we will continue for another 30 minutes or so. h. At 2:06 PM - Pulse in the 80's per minute and his blood pressure has vacillated from the 100's to 130's. He is asymptomatic. As long as we hold this evening's spironolactone he can resume normal medications tomorrow. In a phone interview on 11/1/23 at 3:50 PM, Resident #52's Physician stated he had been made aware of the medication error that occurred yesterday for this resident. He relayed he was quite concerned related to the resident's age being [AGE] years old and his age putting him at even greater risk of side effects. It was his understanding the resident had received his regular morning medications and then had been given another residents meds shortly thereafter. He stated the meds included an anti-hypertensive, diuretic and anti-psychotic medications. He was concerned with hypotension. He stated when he was called on the incident he considered having the facility monitor him closely but it would have required a significant amount of time by the staff and he didn't feel that was reasonable. He felt the resident would be better served being seen by the ER Physician and having the ER staff monitor the resident very closely. He reports he is very happy with his decision as the resident did experience hypotension and the ER was able to administer fluids to assist in raising his BP and he was able to return to the facility. Per review of facility documentation on 11/2/23 at 9:36 AM, Staff C, RN received a written warning for the incident on 10/31/23. Staff C also received the following corrective action in the past: A written warning - final - related to Trileptal 600 mg and Atenolol 25 mg being misplaced and not given to a resident during the evening med pass on 7/10/22. Medications were found the morning of 7/11/22 by a Medication Aide. The resident involved had a seizure on the morning of 7/11/22. Expectation moving forward: Staff C will always follow the 6 rights to medication administration. Staff C will also wait to sign off medications until the resident has been observed to have taken them. On 8/2/21 - Written Warning - Staff C had 2 medication errors in less than 2 weeks. Both of these errors included the drugs warfarin. Expectations moving forward - Staff C will follow the medication policy and observe the 6 rights of medication administration. On 11/2/23 at 10:18 AM, the Administrator reported she had spoken to Staff C and she reported she had given resident #50 all of his medication except for 4, metoprolol, spironolactone, Risperdal, and Lasix. It was the end of the month ([DATE]st) and there were no meds left in the cards for the 4 meds. She reported she gave the others and then went and got the November med cards and punched out the 4 she needed to still give. She punched them out from the 30th of November on each card. She then went to find Resident #50 to give him the rest of the meds and that is when she inadvertently gave them to the wrong resident (Resident #52). This was verified when this writer went to the November medication cards for Resident #50 and those meds had the medication removed from the 30th already. In an email dated 11/2/23 at 12:16 PM, the Administrator reported Staff C had not completed any competencies related to medication administration and the 6 rights of medication administration, however she would be receiving training before her next schedule day to work as part of her corrective action. In an interview on 11/01/23 1:50 PM, the Administrator stated it was the expectation all Medication Aides and nurses follow Physician Orders as written and ensure the right residents receive the right medications by using resident identifiers. In an email dated 11/02/23 10:16 AM, the Administrator reported the facility does not have a policy for medication administration or following the 6 rights of medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews and facility policy review, the facility failed to accurately reflect the needs for 1 out of 3 residents reviewed in regards to supervision and care (Resident #1). Resident #1 was found outside lying on the ground unsupervised in hot weather wearing sweaters. Resident #1 required hospitalization related to heat exhaustion and dehydration. The resident's cognition had declined and the Care Plan was not updated to direct staff on how to keep Resident #1 safe. The facility reported a census of 51 residents. Findings Include: A Minimum Data Set (MDS), dated [DATE], documented diagnoses for Resident #1 that included early onset Alzheimer's disease, abnormalities of gait and mobility, and heart failure. A Brief Interview of Mental Status (BIMS) revealed a score of 3 out of 15, which indicated severely impaired cognition. The resident required supervision of 1 for locomotion on and off the unit, dressing and toileting. An MDS dated [DATE], documented that this resident's BIMS score was a 10 out of 15, which indicated moderately impaired cognition. A Care Plan with a Focus Area dated 10/9/19, documented that Resident #1 had an Activity of Daily Living (ADL) deficit due to Alzheimer's disease. An intervention date 6/28/21, directed staff that Resident #1 was now allowed to go out (to) the courtyard with his forward wheeled [NAME] (FWW) independently. The edge of the sidewalks had been painted yellow to show his boundaries. This resident had been educated on the use of his walkie talkie and to call for assist on channel 6 if he should need help outside. He was to check in with nursing prior to going outside and getting his walkie talkie and then when he came back in, he was to report to the nurse and turn his walkie talkie back in. The above Care Plan Focus Area and intervention were discontinued on 7/5/23. Review of Progress Notes for Resident #1 documented the following: a. On 7/2/23 at 3:43 p.m., another resident went to nursing staff and said that someone was outside with their pants down. Resident #1 was standing at the tree with pants to his knees. Staff went outside and noted this resident's wheelchair was in the grass. Staff advised Resident #1 that he could not be outside. They were able to get his pants on and get him inside. Resident #1 had his coat on and his 2 shirts. Water was given and resident was alert and smiling. This resident's skin was pink, warm, and dry. There was no cyanosis (blueness to skin related to decrease in oxygen) noted. Staff advised this resident not to go outside without help. b. On 7/2/23 at 4:00 p.m., staff had a conversation with this resident about not urinating outside. This resident verbalized understanding and used the restroom indoors. c. On 7/4/23 at 6:00 p.m., Resident #1 found outside in the courtyard when staff were looking for the resident because he did not come out for supper. Staff A, Certified Nurse Aide (CNA), found Resident #1. The resident was lying face down on his right side with feet stretched out in front of him with 1 shoe on and 1 shoe off. Resident #1 was wearing his dress shoes and noted outside for approximately 40 minutes. Staff did not move the resident and Staff B, Licensed Practical Nurse (LPN), stayed with Resident #1 until the Emergency Medical Services (EMS) arrived. Staff were unable to obtain vital signs. When the resident was turned over it was found he vomited and soiled himself. EMS moved and assessed the resident. The resident was lying on the right side of his body with his face on the concrete and his feet stretched out in front of him with the wheelchair behind his head. Resident #1 was unable to give a description of what had happened. Resident #1's range of motion was not checked until EMS arrived. Resident #1 told the nurse that he was having pain but wouldn't tell the nurse where it was located. The resident's skin was warm and he was wearing a coat and 2 shirts on with pants and dress shoes. The resident was to be an assist of 1 with walker and or wheelchair. Resident #1 had an order to go outside to the courtyard with a walkie talkie but didn't have one on him today. The resident was sent to the emergency room (ER) for evaluation and treatment. d. On 7/4/23 at 9:50 p.m., staff spoke with the ER nurse. He voiced that Resident #1 was being admitted related to unresponsive episode. The ER nurse voiced that they needed to run more tests so they could figure out what happened. The Director of Nursing (DON), was informed of the resident's admission to the hospital. e. On 7/5/23 at 5:34 p.m., received a call from the hospital and they are keeping the resident for another day. The hospital staff stated they are reporting this incident to the Department of Inspection and Appeals (DIA). Advised the DON was going to also. f. On 7/8/23 at 9:53 p.m., an admission Assessment documented Resident #1 admitted to nursing facility in a wheelchair from the hospital. Resident #1 was oriented to facility meal times, visiting hours, room and staff. The resident's ADL needs were extensive assist from staff for bed mobility, transfers, dressing, toileting and limited staff assist to complete personal hygiene. Resident #1 was oriented to person and disoriented to place, time, and situation. A Hospital Summary Report dated 7/8/23 documented the following diagnoses were noted on 7/4/23 and resolved on 7/8/23: a. Encephalopathy acute (a disease that affects brain structure or function and causes altered mental state and confusion). b. Rhabdomyolysis (a breakdown of skeletal muscle due to direct or indirect muscle injury, if not treated immediately if can lead to kidney damage). c. Heat exhaustion. d. Dehydration. e. Lactic acidosis (condition where there is too much acid in the body). The Summary of Hospitalization documented that an [AGE] year-old male with advanced Alzheimer's dementia was apparently found down in the courtyard of the facility on a hot day wearing winter clothing for an unknown period of time. Upon arrival to the ER the patient was minimally responsive and febrile to 101 (degrees Fahrenheit). Responsiveness improved once the patient was cooled and given intravenous (IV) hydration. The resident was unable to provide any history due to his dementia and thought he was still at the nursing home. The resident did not remember going outside wearing winter clothing at all. Initial Vital Signs (VS) were positive for fever and mild hypoxia (low oxygen level) with the resident needing oxygen at 2 liters per a nasal cannula. Review of an email sent on 7/25/23 at 12:16 p.m., the State Climatologist of Iowa reported the following weather conditions in response to a request for the weather on 7/2/23 at 3:45 p.m. and for 7/4/23 from 4:00 p.m. to 6:00 p.m.: On July 2, 2023: a. Temperature: 85 degrees F. b. Relative humidity: 48%. c. Heat Index: 86 degrees F. d. Winds out of the Northwest (NW) at 14 miles per hour (mph). e. Mostly cloudy with no rainfall detected. On July 4, 2023: a. Temperature: 86-88 degrees F. b. Relative humidity: 48-53%. c. Heat Index: 92 degrees F. d. Winds out of the South-Southwest (SSW) to [NAME] 7-12 mph. e. Fair conditions with no rainfall detected. On 7/10/23 at 9:30 a.m., no residents were noted to be outside. The Nursing Home Administrator stated they put a Facility Self-Report in today for an incident that happened last week involving Resident #1. She said there was some confusion regarding whether he was in observation at the hospital or not, but they found out he was admitted . When asked how long can a resident be in the hospital before they are considered admitted ? The Administrator stated it depends-sometimes 24 to 48 hours. She said that Resident #1 had fallen outside and went to the hospital. On 7/10/23 at 12:10 p.m., Staff C, Restorative Aide, stated the door alarm sounds at the Nurse's Station. She stated about 2 years ago she had to go outside to get a resident who went outside. She knew about the resident going outside, because of the call light system and she went to check, then saw the resident outside. Staff C reported she has had no other residents that she has had to retrieve since then. On 7/10/23 at 1:00 p.m., the DON stated that there are no residents in the facility that currently use the Wander guard system (a system that has residents wearing a bracelet which will alert staff when a resident is near an exit door). She stated no other residents have been outside that they have had a concern with. The DON reported she would get the timeline for Resident #1's fall outside. When asked if the door alarm sounded alerting the call light system and staff, the DON stated it would have. The DON stated at that time Resident #1 was able to go outside, so staff would have seen him go out and would not have had a problem with that. She stated that on the day he went outside and fell, Resident #1 had a supplement drink around 4:30 and after passing trays, staff noticed he wasn't in the dining room, so went to find him and found him outside, lying on his side. The DON said they wondered if there was something else going on with him like a potential urinary tract infection (UTI), because he was trying to pee outside and he normally didn't do things like that. The DON said he always wears a coat outside and is one who can get combative if you would try to remove his coat. She said he needs help getting over the hump and outside the door usually but on that day, he must have gone over the hump by himself because they could not find any staff that reported they helped him outside. The DON stated he no longer was able to go outside on his own after this incident. Throughout the survey, Resident #1 noted lying in bed with all observations so far of him. On 7/10/23 at 1:22 p.m., Staff A, CNA stated she had got to work a little late so she didn't take report from anybody (on the day of the incident). She stated her partner had taken report. That day Resident #1 was in bed around 3:00 p.m. He usually was in bed for lunch and supper. She stated that day she arrived to the facility about 2:10 p.m. or 2:15 p.m. Staff A stated she was supposed to leave that day at 6:00 p.m., so she was giving report to another CNA and was telling her what happened during the 4 hours Staff A had worked. Staff A stated she was ready to leave, in the breakroom when a staff member who worked in the kitchen, asked about where Resident #1 was. Staff A stated she then went back to his room. Staff A told the other CNA to walk with Staff A so she could finish giving report. Staff A stated that Resident #1 was not in his room and he was not in his bed. Staff A stated a resident across the hall had her curtains open and Staff A saw a wheelchair out in the courtyard. Staff A stated they then went outside, saw Resident #1 on the ground, had the other CNA go check on him while Staff A ran to get a nurse. Staff B, LPN was the nurse on the other side and she came right away. Staff A stated this resident's nurse and his other nurse were arguing about who was going to take care of him. When asked how Resident #1 seemed to be doing, Staff A stated that Resident #1 was lying on the ground. She stated he responded to them. Staff A stated she thought Resident #1 was hot because it was hot outside. Staff A stated Resident #1 usually wore about 5 jackets. Staff A reported Resident #1 could go outside by himself. She stated she had seen him go outside by himself before, but she did not see him go outside by himself on that day. She said he was lying on the cement area without any obvious injuries. Staff A stated the Paramedics removed Resident #1's jacket after responding quickly after they called the Paramedics. Staff A stated she ended up leaving around 8:00 p.m. Staff A stated that she wasn't sure what time Resident #1 left the facility. She stated the Paramedics cut off Resident #1's clothes and they were out there for about 10-20 minutes. Staff A stated that because Resident #1 was laying like facing the cement, Staff B had said she did not want to move him because of the way he was lying. Staff A stated that half of his face was facing the ground and his arm was under him, so they didn't know if he had a broken arm or anything like that. Staff A stated when she said Resident #1's name he said yes, but he was moaning like he was in pain. Staff A stated that Resident #1 was in his room when she had seen him earlier and had heard the (door) alarm. Staff A did not know if anyone saw him and she did not know who shut off the alarm. Staff A stated that it was very busy that day and she was used to working on the other side. It was different because they have new residents. She stated they have another resident who was trying to open the door. Staff A repeated that they did not know who shut off the main box that is at the Nurse's Station. Staff A said the facility had a few residents who go outside without asking and the nurse that is usually behind the desk is supposed to be checking the box. When asked about a walkie talkie, Staff A stated that Resident #1 used to carry a walkie talkie when he was walking but it had been a long time since he walked. Staff A stated she worked as needed (PRN) so she did not know for sure how long it had been since he was walking, thought it had been a few months. Staff A stated she had not seen Resident #1 carry that walkie talkie for a long time. Staff A repeated that she last saw him about 3 something that day, it was probably 3:30. Staff A reported that supper was served at 5:00/5:30 p.m. On 7/10/23 at 2:00 the Administrator stated Resident #1 did not have a walkie talkie on him. She stated Resident #1 probably hadn't used a walkie in a long time. The Administrator stated Resident #1 used to go up to the Nurse's Station and ask for a walkie. The Administrator stated everyone should be aware of the alarms. We all know what times the smoke times are. The Administrator stated if staff do not see anyone at a door that triggered an alarm then staff are to go down the hall to find who went out. She stated that if staff aren't able to see who went out the door, then staff should go into the facility's Elopement Protocol and make sure all residents are accounted for. She stated that the facility needed to get clarification on if anyone saw him go outside. Initially Staff D, Registered Nurse (RN), stated she did see him go outside but then when the DON asked her the next day, Staff D stated she did not see him go outside. The Administrator stated that Staff D was coming in later that day and they were trying to get down to the bottom of it, whether or not Staff D let him out. When asked about him being outside on 7/2/23, the Administrator stated she was unaware of this incident. The Administrator stated that Resident #1 has had to be redirected before when he had urinated inappropriately outside. The Administrator stated that was when Resident #1 was walking. The Administrator stated that she was unaware of him urinating inappropriately since he's been using a wheelchair. The Administrator stated she wanted to say it had been 3 to 6 months since Resident #1 had been using a wheelchair. She stated Resident #1 was starting to use his walker unsafely so the facility switched him to a wheelchair. The Administrator stated that Resident #1 could still transfer and pivot. On 7/10/23 at 2:24 p.m., Staff F, RN, stated that (on 7/2/23), another resident had come to Staff F and said that Resident #1 was outside by a tree peeing. Staff F stated she went out and sure enough he was peeing and had his pants down. She stated they were able to get his pants back up and get him back on to the hard surfaces as he was on the grass. Staff F stated that Resident #1 had not gone outside for the longest time. Staff F stated she did not know if he had recently gone outside before that. Staff F said Resident #1 used to bring a walkie talkie with him. Staff F stated she got Resident #1 all checked out and made sure he had clean clothes on. She said he was acting fine. She stated it happened around midafternoon. Staff F stated she did look at his Care Plan and it did say he could go outside with a radio. Staff F stated she reported it on to the Night Nurses on the 24-hour report. Staff F stated that Staff E, Quality Assurance Nurse, had to come in because someone called in sick on the night shift. Staff F stated Staff E came in and Staff F told Staff E what had happened. Staff F stated she had no idea about whether the alarm had sounded. Staff F stated she had just sat down and was getting ready to chart when the other resident came up and told her about a Resident peeing outside. Staff F stated she just finished passing the 2:00 p.m. medications. Staff F stated there was no alarm going off then. Staff F stated that originally Resident #1 would go out with people that would go out smoking, but that was a long time ago. Staff F stated she worked 3 days a week. On 7/10/23 at 3:15 p.m., Staff G, LPN, stated that she had only been working at the facility for a short while and mostly worked days. Staff G stated that Resident #1 did not really go outside much during the day hours. Staff G stated when she worked a 2nd shift a couple of weeks prior and Resident #1 went in and out a few times on that shift, he would let himself out and then let himself back in. Staff G reported that staff told her that Resident #1 does that all the time. Staff G reported that Resident #1 opened the door safely when she saw him. On 7/10/23 following the above conversation, Staff H, CNA, stated she had worked at the facility for over a year. Staff H stated she had just recently come back to the 2-10 shift from nights about a week prior. Staff H stated that she heard about Resident #1 falling. Staff H stated that Resident #1 used to have a walkie and she wouldn't have thought anything about him going outside because he did that all the time last year. Staff G stated she had not seen him go outside this year though. On 7/10/23 at 3:44 p.m., Staff I, LPN, stated that she was not working either day this resident was found outside but it was something he would do fairly regularly. Staff I reported she had not seen him go out lately, but he had gone out and sat in the courtyard. Resident #1 was out for a classic car show. She stated if she would have saw him going out it would not raise an alarm to her. Staff I stated Resident #1 would go outside with another resident as well. Staff I stated Resident #1 wears his coat constantly. Staff I stated when this resident was out at the car show she tried to get him to come in. Staff I stated Resident was wearing a hat and gloves and he refused to take them off. She stated this resident sleeps all day and gets up at night. He wakes up during the day and will ask for a supplement drink. Staff I stated Resident #1 would be awake during the day, you can go in and talk with him. Staff I stated as far as getting out of bed this resident would wait to get up until after supper. Then he would go down and play cards. On 7/10/23 at 4:08 p.m., Staff J, CNA, stated she wasn't working when Resident #1 was found outside. Staff J stated she worked full time on 2nd shift, and Resident #1 would normally go outside so she wouldn't have thought twice about him going outside. Staff J stated she had worked at the facility for 9 years. Staff J stated that Resident #1 was able to get in and out of the door without any issues. Staff J reported that she knew one time he went out with the jacket on and it was in the 70's. Staff J stated that she made a comment to the nurse and Resident #1 came right back in though. Staff J explained Resident #1 used to use a walkie talkie outside with him but that had been a while ago. She stated he used to come up to the Nurse's Station and get the walkie talkie. Staff J stated the last time she saw him do that was a few months ago. Staff J stated the resident stopped telling us he was going out recently. Staff J stated she hadn't seen a change cognitively. He still takes care of himself. Staff J stated that she personally did not know if the wheelchair was something Resident #1 wanted to be in. On 7/10/23 at 4:23 p.m., the DON stated she had received a text message saying to call the facility. The DON called the facility back and was told that Resident #1 was on the ground outside and was told what was going on. The DON came in around 7:40 p.m. to 8:00 p.m., and started her investigation on what had happened. The DON stated that Staff B, LPN said she had seen this resident around lunchtime. The DON stated that Staff D said she saw him around 4:30 p.m., at the desk when this resident received a supplement and then around the 5:40ish p.m., staff went to look for him and that's when they found him outside. The DON stated she was not aware of the incident of him urinating outside. The DON stated she looked at the Care Plan and had gotten it all updated. The DON stated she understood the concerns. On 7/10/23 at 4:31 p.m., Staff D, RN stated she had worked the dayshift when Resident #1 had fallen. Staff D stated she had seen Resident #1 when he came up for a Boost (dietary supplement). She stated that 4:30 p.m. was probably the right time as this resident wants a Boost before supper. Staff D stated she honestly did not know what time it was, but was afternoon before supper. Staff D reported Resident #1 did not show up for supper and one of the girls was going and getting the residents up for supper. Staff D stated that Staff B, LPN was working also and Staff B ended up going out and taking care of him. Staff D stated that both she and Staff D were getting ready to leave. Staff D stated she did not see Resident #1 go outside. Staff D stated she honestly did not remember the alarm going off on the door and added that it gets so noisy and the alarm goes off all day long. She stated 2 other residents go out all the time and they were care planned to go out. Staff D stated that if she was at the Nurse's Station and heard the alarm go off, she would see who was going out and if it's okay, then she would shut the alarm off. Staff D stated that if they staff did not know where the alarm was coming from they would go and check to see if someone accidentally went out. Staff D did not think any of these people have any business going in or out. She stated the facility did not have enough staff to ensure that the residents are safe. Staff D stated she did not think a resident could be Care Planned to go out there safely. Staff D stated that the last she knew, Resident #1 was care planned to go in and out by himself. Directly following this interview, the Administrator and the DON stated they understood the concerns with the level of this resident's impaired cognition and the facility allowing him to independently go outside. They acknowledged that the Care Plan should have been updated to reflect his changing needs. The facility reported they did not have policies on Care Plans, Nursing Supervision, or Rounding and Resident Checks. The facility reported they follow regulations and Nursing Standards of Practice. Review of the Missing Resident/Elopement Process policy revised on 7/12/21, directed staff under the Assessment and Identification of Wandering Residents Section: a. An elopement risk assessment will be completed upon admission, readmission, quarterly, annually, and with any significant change MDS. b. Care Plan will be modified as needed based on risk assessment. c. You will complete a missing resident identification form. d. Activities will be in charge of having a missing resident identification form completed for each resident on admission and annually by the end of the first quarter (March 31st). Under the Residents identified at Risk for Elopement Section: a. Residents whose assessment identifies them at risk for elopement, the following steps will be taken: i) An alarm bracelet may be placed on the resident to audibly alert the staff of attempts by the resident to exit the facility. ii) The resident's Care Plan shall address behaviors using resident specific goals and/or approaches as assessed by the Interdisciplinary Team (IDT). iii) A current picture of the resident will be maintained in the facility. iv) Facility staff will ensure that all exit alarms are responded to immediately. v) Staff will encourage activities which the resident enjoys in order to occupy/distract the resident. WHEN THE DOOR ALARM SOUNDS; the facility staff shall: a. Check the alarm panel to determine which door has been opened. DO NOT assume someone else has already done this. b. Check the exit door for any existing resident by means of a visual check. Visual check means observing the area around the exit and may require leaving the building. c. If a resident is discovered outside the facility inappropriately, staff will assist them back into the facility. d. Reset the door alarm after it is determined by visual check that no resident has exited the facility inappropriately or is returned to the facility. e. If for any reason, door alarms are turned off, the staff will continually visually monitor the door/doors. f. If an alarm is discovered de-activated, staff will perform an immediate head count to ensure all residents are accounted for. The Nurse, DON, or Executive Director will question staff to determine who de-activated the door alarm and reason for doing so. If the Nurse, DON, or Executive Director in advance did not approve the de-activation, the person responsible for de-activating the alarm may face disciplinary action. Disciplinary action issued for such occurrence shall be maintained by the DON or Executive Director. Elopement Process (Missing Resident): 1) When it is determined that a resident is missing, the following will occur: i) Alert the nurse in charge and all shift personnel to search the facility. If the resident is not located, institute a grounds search. ii) If the resident is unaccounted for after a thorough grounds search of the building and grounds, the following will be immediately notified: a) Executive Director/ Director of Nursing b) Family and/or Legal Representative c) Attending Physician d) Police A complete description of the resident will be given to police along with a current photo of the resident. Provide law enforcement the Missing Resident Identification Form. When the resident is located, the following procedures will be followed: a. Head to toe assessment of the resident will be completed to determine if medical attention is required. Document in Nurse's Notes - Head to Toe Assessment completed and findings. b. After assessment is completed, the attending physician will be notified, and results of assessment reported. The Physician's Plan of Care will be documented in the resident's record. c. The resident's family/legal representative shall be notified of the resident's condition. d. The resident's condition will be monitored every shift x 72 hours. e. A detailed Incident Report will be completed. f. An Elopement/Missing Resident Investigation Form will be completed by the DON and/or designee. g. The Incident Report will be reviewed at the Monthly Safety Committee meeting and each quarter with the QA Committee. Education and Training: a. All staff will be educated on proper identification, assessment, and treatment of residents identified as an exit seeking risk. This education will occur during orientation and annually thereafter. B. Missing Resident Drill will be completed on ALL shifts quarterly. Attachments: a) Missing Resident Identification Form. b) Elopement/Missing Resident Investigation. c) Missing Resident Drill.