**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 51 residents. The sample included three residents reviewed for elopement (when a cognitive impaired resident with little or poor safety awareness exits the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to identify the increased level of risk and respond with appropriate interventions and adequate supervision, to prevent an elopement for Resident (R) 1, who was cognitively impaired, at risk for elopement, and had a recent history of aggressive exit seeking behaviors on 02/07/23 and 02/09/23. On 02/16/23 the facility placed a Wander Guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on R1 and removed the resident from one-to-one supervision, though not all doors were connected to the Wanderguard system. On 03/08/23 at 03:36 AM, R1 exited the facility from the alarmed South door, not included in the Wander Guard system. Staff responded to the door alarm, looked outside, and then canceled the alarm. Staff searched for R1, and noted his bed was made in a way to appear as if he was in bed. Staff alerted Administrative Staff A, and then later called Law Enforcement (LE). The area surrounding the facility was searched but R1 was not found. Three and a half hours later, R1 was found in the ditch adjacent to the facility property. R1 was cold and wet, more confused than usual, and transferred to the local hospital for assessment. The facility failed to reassess R1 after his previous elopement/exit seeking attempts and implement preventative interventions, which included adequate supervision, to ensure R1 did not leave the facility without staff knowledge. The facility staff also failed to immediately conduct a thorough outside search when the South door alarmed. This deficient practice placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnoses tab recorded diagnoses of hepatic encephalopathy (loss of brain function as a result of failure in the removal of toxins from the blood due to liver damage), hepatic failure (a condition in which the liver is unable to perform its normal metabolic functions), and neuralgia and neuritis (a sever pain due to damaged nerves that causes severe burning pain). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R1 required limited assistance of one staff member for bed mobility, dressing, toilet use, and personal hygiene. R1 required supervision of one staff member with transfers, walk in room and corridor, locomotion on the unit, and eating. R1 only required supervision and set up help with locomotion off the unit. The MDS noted R1 had daily wandering behavior present that placed R1 at significant risk of getting into a potentially dangerous place. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 02/09/23 documented R1 had daily wandering behaviors and placed R1 at significant risk of getting to a potentially dangerous place. The Cognitive Loss CAA dated 02/09/23 documented R1 had long-term and short-term memory loss related to liver failure and received medications to aid in memory. R1 had impaired decision-making abilities. The Urinary Incontinence CAA dated 02/09/23 documented R1 was a fall risk related to weakness and poor safety awareness with a goal of possibly needing placement in a locked unit related to confusion. The Behavioral Symptoms CAA dated 02/09/23 documented R1 had behaviors of wandering around the facility, and the licensed Nurse (LN) tracked and documented those in the treatment administration record (TAR). The Care Plan dated 02/03/23 directed staff to encourage independence while R1 was in the building but ensure supervision while outside, observe for signs and symptoms of acute illness which may enhance confusion, and to redirect R1 when wandering around doors and/or exits. It directed staff to visualize R1's whereabouts, frequently. The care plan further recorded an intervention dated 02/13/23 which documented a history of refusing/resisting ADL cares and directed staff to keep R1 out of others' rooms and keep him from exiting the front doors. An intervention created on 02/13/23 directed staff to provide one-on-one assistance with one staff member, related to exiting. R1's Care Plan noted on 02/16/23 R1 had a Wander Guard placed on his left hand. The Wandering/Elopement Risk Scale Assessment dated 02/03/23 documented a score of five, which indicated low risk for wandering/elopement but documented in the notes section that R1 had exhibited behaviors of wandering since admission and was observed wandering in and out of other residents' rooms. R1's clinical record lacked further elopement/wandering assessment until after the elopement on 03/08/23. The Orders - Administration Note dated 02/04/23 at 08:10 AM documented R1 was wandering. The Behavior Note dated 02/06/23 at 09:09 AM documented R1 had one-on-one care with exit seeking, aggressive behavior toward staff, and wandering. The Health Status Note dated 02/07/23 at 04:23 PM documented R1 continued with one-on-one monitoring and every 15-minute checks. R1 walked around the halls several times so far on that shift. The Alert Note dated 02/07/23 at 06:57 PM documented R1 headed toward the lobby and walked up to the front doors, turned off the button at the top of the doors, and tried to walk out of the facility. An unidentified Licensed Nurse (LN) tried to stop R1 from leaving and had to yell for assistance. An unidentified Certified Nurse Aide (CNA) responded and the LN was able to redirect R1 back inside. The LN reported the event to Administrative Nurse D. The note documented R1 was halfway out the second door and staff had to gently take R1 by the arm and turn R1 around to bring him back into the building. The note documented R1 tried to leave the facility on three separate occasions the previous night and staff had to constantly watch R1 all night. The Behavior Note dated 02/09/23 at 09:44 AM documented clarification that R1 was not aggressive towards staff but was aggressively exit seeking and consistently wandered. The Nurse's Note dated 02/11/23 at 10:07 PM documented R1 remained restless and confused. One-on-one nursing monitoring continued. R1's EMR, under the Orders tab, documented a Physician Order dated 02/16/2023 which directed staff to ensure R1 had a Wander Guard every shift. R1's clinical record lacked further documentation related to the Wander Guard placement. The Nurse's Note dated 02/20/23 at 05:09 AM documented R1 remained restless and walked around the facility. R1 voiced he had nausea and staff encouraged him to rest, but he refused. R1 had confusion and was going through the activity area closets. The Nurse's Note dated 03/08/23 at 11:01 AM documented at 03:30 AM the south hall door alarmed indicating that it was opened. LN G, CNA M, CNA N, and CNA O checked the door and outside the surrounding area but were unable to visualize anyone in the vicinity. The staff checked R1's room. The noted documented R1 was ambulatory and wore a Wander Guard. R1's bed had bunched up blankets underneath the covers in the general shape of a body laying in the bed. LN G, CNA M, CNA N, and CNA O then searched the facility and the property. Staff notified Administrative Staff A who then notified LE when R1 was not located on the property. LE arrived at the facility and assisted the additional staff on site with the search. R1 was located laying down outside at approximately 07:10 AM and then transferred to the hospital for evaluation. Review of the facilities Incident Report noted on 03/08/23 at approximately 03:35 AM, the alarm sounded, alerting staff that a door was opened. CNA M went to the control panel located behind the long-term care charge nurse station to see which door was opened. The report documented CNA M, along with CNA N and CNA O, went outside of the south hall door and surveyed the surrounding area without seeing any person. Upon entry back to the building, the CNA staff notified LN G and began a head count, starting in R1's room. When staff looked in R1's room, they found R1's bed had blankets and clothing items lumped under the bedding to make it look like the resident was still in bed. The report noted staff continued searching with the head count in the building then moved the search outside the building. The report documented the staff notified Administrative Staff A, who then notified LE at 03:40 AM. The report noted that local LE took over the search using heat signature [NAME] and foot officers at 04:15 AM. The report noted at approximately 07:05 AM Dietary BB reported to CNA P that Dietary BB saw a person laying in the grass ditch outside the building. CNA P notified Administrative Staff A who flagged an unidentified LE officer over while Administrative Staff A headed to the area. The report noted at 07:10 AM, R1 was located about 80 feet from the building, laying on trash bags, wearing a hoodie, sweatpants, shoes and socks and socks on his hands. He was covered by a blanket. The gate chain [from the facility fence] was on the ground next to R1. The temperature at that time was 45 degrees Fahrenheit (F). The report indicated the video footage recorded R1 left his room with a packed bag at approximately 03:35 AM. R1 removed his Wander Guard in the small breezeway that linked the middle and south hall and exited the building on the end of the south hall, which was directly by the gate, to get out of the garden. The report documented R1 admitted to the facility on [DATE] with a BIMS of three, noted he originally did not score as an elopement risk, however he did have behaviors and a history of wandering to exits. He was placed on one-to-one from the time of admission on [DATE] until 02/16/23 as the facility waited on the Wander Guard shipment to arrive. On 02/16/23 the staff placed the Wander Guard on R1, related to R1's increased wandering with exit seeking. The report noted the elopement system in place was completed correctly by the staff; the door alarm triggered, and staff immediately acted verifying which door alarmed. Staff went directly to the door to complete a search of the immediate area. When staff saw no residents at the door or the surrounding area, staff began searching inside and completing a head count. Staff identified R1 was missing and began searching inside and outside of the building. The hospital History and Physical (H&P) dated 03/08/23 documented R1 lived at the facility due to hepatic failure and encephalopathy. He was last seen in the nursing facility at 02:00 AM. The H&P recorded R1 was found in a ditch by the facility; he was wet, cold, and confused and admitted to the hospital by ambulance at 07:46 AM. His body temperature was recorded at 36.4 degrees Celsius (97.5 degrees Fahrenheit) and in no acute distress. In a notarized Witness Statement dated 03/14/23, CNA M stated the door alarm sounded around 03:30 AM. CNA M stated she saw it was the south hallway and went right to the door to check it but did not see anyone, so staff went to R1's bedroom. They noted R1 made his bed to appear someone was still in it. CNA M stated when staff observed R1's bed, each staff took a hallway and looked in every room, and then started searching outside. In a notarized Witness Statement dated 03/14/23, CNA N stated the nurse and two other CNA were at the nurse's station at approximately 03:30 AM, when the south hallway door alarm went off. The three CNAs went to check it out. CNA N stated staff did not see anything outside and went over to the hallway where R1's room was located. CNA N stated one CNA turned on R1's lights and staff saw R1's bed was stuffed. CNA N stated staff then split up and looked down every hallway and searched outside. CNA N stated she went with another CNA to the apartments [located near the facility] while another staff drove around the surrounding block. Staff came back to the facility and searched inside again and called the admins. In a notarized Witness Statement dated 03/14/23, CNA O stated the door alarm went off down the 100 hall and CNA O and CNA N rushed down to the door, looked outside no one was near. CNA O stated they went and checked R1's bed and noted the bed had been stuffed to look occupied. CNA O stated staff then searched outside, yelled R1's name, and searched the entire building. The LE Incident Report recorded a 911 call received at 04:02 AM on 03/08/23 from Administrative Staff A alerting LE that R1 had left the facility against medical advice. LE arrived at the facility and Administrative Staff A informed LE that R1 had been at the facility approximately 30 days and had health issues related to his liver disease. Administrative Staff A told LE that at approximately 03:40 AM one of the facility alarms went off, and when staff checked the facility, they found that R1 had placed blankets and pillows in his bed forming them to look like a person was sleeping, then went down the southeast hallway and out the south door. The report indicated LE officers began searching the area on foot and in patrol cars. LE notified local county LE and requested the use of a thermal imaging drone. Multiple deputies responded and assisted in the search. LE officers conducted a grid search, as well as a one-mile drone search to seek out heat sources. Officers conducted a foot search of the adjacent golf course as well. At 06:00 AM, after the search efforts were exhausted, the county officers were cleared from the call and local LE continued to search the area in patrol vehicles. The report noted at 07:00 AM, LE received notification from a caller who reported a man laying in the ditch at an intersection just north of the facility. LE arrived at the scene and visualized R1. The report indicated it appeared as if R1 slipped while returning to the property, R1 appeared uninjured but did not want to return to the facility. The report noted it was determined that R1 travelled north on foot after leaving the facility and went to the local general store to get a lighter and a drink. On 03/14/23 at varying times throughout the survey, observation revealed the facility was in an [NAME] area along a two-lane road with posted speed limits of 30 miles per hour (MPH). R1's exact route was unknown although the resident would have had to walk down an incline exiting the premises. The general store was located over a mile away, on a busy two-lane highway with posted speeds of 35 MPH. According to Wunderground.com, the weather outside on 03/08/23 between 03:35 AM and 07:05 AM was approximately 41 degrees F. On 03/14/23 at 12:25 PM Administrative Staff A stated that R1 had never actively tried to get out of the building. Administrative Staff A further stated the elopement was a new behavior for R1 and that R1 only tinkered with things which was why R1 received a Wander Guard, just for his safety. On 03/14/23 at 12:40 PM Administrative Nurse D stated that when there was a change in a resident's wandering or elopement behaviors from the previous wandering/elopement assessment, she expected the nurses to complete a new wandering/elopement assessment. On 03/14/23 at 12:45 PM R1 stated he tried and tried to get the facility's attention but the facility would not listen to him. R1 revealed he took a small blanket, plastic bags in case he needed to lay down, napkins for toilet paper because his bowels had not been good, and lastly a lighter in case he needed to make a fire. R1 further revealed that he wanted to walk back to the city which he formerly resided. R1 stated he went through the small hallway that connected the two halls and exited the doorway on the parallel hallway. Once outside, he turned right and went through the gate and then closed the gate and went left once outside of the gate. R1 said he went left again at the corner of the chain link fence down to the parking lot. R1 revealed the ground was slick from the rain and that it had started to rain on him again while he was out walking. R1 stated after leaving the parking lot he walked on the sidewalk and noted that he was tired. R1 stated at that time he laid out a plastic bag in the ditch so he could rest. R1 laid down and then covered himself with leaves to help keep him warm. R1 revealed he wanted the police called and thankfully the police helped find him. R1 stated he had not slipped but he was cold and wet when he was outside. He said he rubbed his hands together and would blow warm air into them to try to stay warm. R1 stated he felt like no one found him because of the color of his coat and he had pushed leaves up on himself. R1 held up a darker brown farming coat with a zipper and hood. On 03/14/23 at 02:10 PM CNA M stated when the alarm went off that night, she went to the door and looked outside. CNA M further stated she went outside and noted the gate was closed. CNA M revealed she had last seen R1 at approximately 02:00 AM when assisting R1's roommate. CNA M stated R1 laid in bed watching TV and appeared calm. CNA M stated she searched the back, bottom parking lot but did not go out on the grass at all. CNA M revealed that she performed R1's one-on-one the following day, 03/09/23, and asked R1 if R1 heard CNA M yell his name. R1 stated he had, and that CNA M yelled loudly. CNA M revealed that R1 wandered and tried to go outdoors, historically. CNA M further revealed R1 had been a one-on-one for a long time, but had eased up on exiting, so the facility eased up on the one-on-one with R1 and then, after a period, the constant monitoring was not continued. On 03/14/23 at 02:30 PM CNA N stated it took approximately three minutes to reach the door, and she did go out the door to look for a resident. CNA N noted the gate to the right had no chain on it and could be opened freely. CNA N revealed that upon coming back into the building she went immediately to R1's room because CNA N knew R1 had previously been on one-on-one, related to wandering. When R1 was not located in his room, staff then went outside to search, while CNA N started to check other resident rooms related to R1's history of going into other residents' rooms. CNA N reported R1 had previously been noted in his room during the 02:00 AM check and change. CNA N said the staff working looked in on R1 when a call light was answered down R1's hall, related to R1's history of wandering and attempting to get out. On 03/14/23 at 03:07 PM Administrative Nurse D stated R1 displayed behaviors of going to doors and that was why R1 had one-on-one. Administrative Nurse D reviewed R1's wandering/elopement assessment at that time and stated she should have known R1 was an elopement risk. She stated Administrative Nurse E handled the admission audits and Administrative Nurse E would have reviewed R1's wandering/elopement assessment. Administrative Nurse D revealed the clinical team was more focused on R1's behaviors and what was being observed at that moment, she said the clinical team was making sure staff were in place to monitor R1, before the Wander Guard arrived. On 03/14/23 at 03:08 PM Administrative Staff A stated R1 had one-on-one monitoring the moment he arrived and R1 was not attempting to leave the building. R1 received a Wander Guard. When asked about R1's progress notes on 02/07/23 Administrative Staff A revealed R1 had stepped outside the door, but staff got R1 back in the door. Administrative Staff A further revealed R1's behaviors had not changed, and the facility awaited the Wander Guard delivery. R1 had a cognition of three out of 15 and R1 was going to doors, and that was why the facility placed a Wander Guard on R1. On 03/14/23 at 03:55 PM LN H stated that R1 wandered and exit-sought frequently. LN H revealed that when R1 initially arrived that was not the case, but then R1 started to change and started to wander. LN H revealed that was when R1 was placed on one-on-ones. LN H stated that one-on -one happened for a while, then R1 received a Wander Guard. LN H stated that if a resident at the facility was noted to change and start to wander, LN H would complete a new wandering/elopement assessment and a change in condition assessment to show the change. LN H further revealed that the front door and the North door that led out to the smoking area were the only two doors connected to the Wander Guard system, since residents had historically either gone to the front door or the smoking door to get out. The facility's Elopement and Wandering Residents Policy, lacked a date, documented the facility would ensure that residents that exhibited wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility failed to identify the increased level of risk, and respond with appropriate preventative interventions and adequate supervision, to prevent an elopement for R1, who was cognitively impaired, at risk for elopement, and had a recent history of aggressive exit seeking behaviors when the facility failed to reassess R1 after his previous elopement/exit seeking attempts and implement preventative interventions, which included adequate supervision, to ensure R1 did not leave the facility without staff knowledge. The facility staff failed to immediately conduct a thorough outside search when the door alarmed. This deficient practice placed R1 in Immediate Jeopardy. On 03/09/23 the facility completed the following corrective actions: The facility conducted in-service training and education to staff with regards to elopement policy and procedure as well as wandering behaviors. Elopement drills and spot checks were completed over all shifts. The facility added an additional camera to view the south hall door and a camera in the dining room for the fire exit door on 03/09/23 which will have video surveillance for all exit doors within the building. Stop signs were ordered and placed on both middle and south doors as visual indicators. When R1 returned to the facility on [DATE] a one-to-one with staff was put in place and R1 set to be reassessed prior to being removed. R1's elopement assessment was updated and noted with a score of 12, which indicated he was at high risk for elopement and/or wandering. R1's plan of care was updated to include interventions which addressed his varying mentation and risk for elopement and/wandering. The above corrections were completed prior to the start of the onsite survey, so the deficient practice was cited as past-noncompliance.