Based on observations, interview with residents and facility staff, and review of residents' medical records, facility policy, and facility quality assurance and performance improvement (QAPI) material, it was determined that the facility failed to have an effective system in place to prevent cognitively-impaired residents from leaving the facility without adequate supervision. This was evident by the facility's failure to: 1) monitor wander guard placement on Resident #59's person and wheelchair, 2) perform an investigation into Resident #59's first elopement attempt on 9/7/18, 3) prevent Resident #59's second elopement on 10/4/18 for almost 40 minutes in the middle of the night, 4) perform and document staff education following either elopement, and 5) secure or monitor the front door during nighttime hours. This was true for 1 (Resident #59) of 8 residents reviewed for elopement. Elopement is the act of a resident leaving the facility unattended when the resident is physically, mental, or cognitively impaired to the extent that s/he is not safe unaccompanied. A wander guard is a device worn by residents who are at risk for elopement that triggers an alarm or a lock when the resident approaches an armed exit. As a result of these findings, a state of immediate jeopardy was declared on 8/2/2019 at 10:50 AM and was removed on 8/5/2019 at 11:59 AM. The findings include: 1) An investigation into facility reported incident MD00132103 was initiated by surveyors on 7/31/2019 at 11:48 AM regarding an elopement by Resident #59 that occurred on 10/4/18. Review of Resident #59's medical record began at this time and revealed that the resident had been admitted to the facility with the diagnoses of alcoholic cirrhosis with ascites and Korsakoff syndrome. Two physicians had certified that the resident was unable to make his/her own decisions at the time of admission into the facility on 9/1/2018. Both alcoholic cirrhosis and Korsakoff syndrome are results of long-term alcohol use. Alcoholic cirrhosis is a condition in which the liver does not function properly due to long-term damage from alcohol. Korsakoff syndrome is a disorder in which the brain suffers damage due to thiamine depravation and is exacerbated by the neurotoxic effects of alcohol. Someone suffering from Korsakoff syndrome experiences loss of memory, apathy, and a lack of insight into all aspects of life. Further review of Resident #59's medical record revealed that the resident had an elopement about one month prior to the reported elopement on 10/4/18. The earlier elopement occurred on 9/7/18 and was detailed in the following nurse's note written on 9/7/18 at 11:42 by the then Assistant Director of Nursing, Registered Nurse (RN) #13: Resident out of building on sidewalk area. Agreed to come back in facility and call his/her significant other. Door alarm did not activate when resident exited. Resident's wander guard not present on him/her. New wander guard placed on right wrist and another placed on his/her wheelchair. Found old wander guard on his/her bedside table. RN #13 was interviewed on 8/1/19 at 10:24 AM. During the interview, RN #13 stated that she saw Resident #59 eloping while looking out her office window in the morning of 9/7/18. She recalled that the resident had already exited the facility and was just barely off the property. She stated that she was able to run outside and redirect Resident #59 into the building without resistance. She also recalled placing two wander guards on the resident, one on his/her wrist and the other on his/her wheelchair. When asked if this information was recorded anywhere else in the medical record, she replied that she believed it was not the facility's practice to change care plans or alter orders when a new wander guard, or multiple wander guards, were placed on a resident. Most likely I only mentioned in a progress note that I put a wander guard on the resident's wheelchair. RN #13 indicated that Resident #59's primary clinical staff were involved in returning Resident #59 to his/her room but that it was not her expectation, in her capacity as Assistant Director of Nursing, for the nursing staff to complete an incident report, obtain new orders, or alter care plans. RN #13 reiterated that this event was not considered an elopement by the facility. Review of physicians' orders for Resident #59 revealed that the resident had an order for Check wander guard every shift for proper functioning with a start date of 9/2/2018 that was active at the time of the elopement. No further note could be found associated with the order that indicated the quantity or locations of wander guards that required checking. Review of Resident #59's care plan failed to reveal that quantity or locations of wander guards on the resident were specified anywhere. Finally, review of the medical record between 9/7/18 and 10/4/18 (the date of the second elopement) failed to reveal observations of the locations of wander guard units on Resident #59 and his/her equipment. Although nursing documented a wander guard check in Resident #59's Treatment Administration Record (TAR) each shift, the location of the wander guard was not included in any of these observations. Ongoing review of the facility's investigation into Resident #59's elopement on 10/4/19 revealed that the resident eloped early in the morning from the front door of the facility (which was armed with a wander guard alarm panel) while using his/her wheelchair. It was also noted in the investigation that the wander guard alarm panel did not alarm when the resident passed it. However, only one wander guard unit was located after the elopement. Because the quantity and location of wander guard units for Resident #59 were not noted anywhere in Resident #59's medical record after the 9/7/18 elopement, it could not be determined if staff were observing one or two wander guard units on Resident #59 when they performed their inspection every shift and documented in Resident #59's TAR. As a result, staff could not show that they had been assessing for the wander guard unit on Resident #59's wheelchair that had been placed by RN #13 expressly to prevent future elopement given the tendency of the resident to remove his/her wander guard bracelet. 2) Review of Resident #59's medical record on 7/31/19 at 11:48 AM revealed that the resident had eloped twice in 2018: on 9/7/18 and on 10/4/18. Review of facility reported incidents sent to the Office of Health Care Quality revealed that only the elopement on 10/4/18 had been reported as an elopement. This was confirmed in interview on 8/1/19 at 9:00 AM with the Director of Nursing (DON), Quality Assurance and Performance Improvement (QAPI) Coordinator, and Assistant Administrator. During the interview, they stated that, because the resident did not leave facility grounds on 9/7/18, they did not consider it an elopement and did not complete an incident report nor send the elopement into the office. Review of the facility's policy regarding elopement revealed the definition of elopement as follows: Elopement is an incident where a resident leaves the facility and he/she is physically, mentally, or cognitively impaired to the extent that she/he is not safe unaccompanied. Any information, investigation, and education that the facility had in relation to this first elopement on 9/7/18 was requested from the facility on 8/1/19 and on 8/2/19. No investigative material or evidence of education performed in relation to this elopement was provided to the survey team prior to survey exit. 3) Review of facility reported incident MD00132103 revealed that Resident #59 eloped in the early morning of 10/4/18. The resident was seen by Geriatric Nursing Assistant (GNA) #5 traveling past the North Hall nurse's station via wheelchair at 1:40 AM. At 1:50 AM, because of a strange noise, Licensed Practical Nurse (LPN) #9 went to the front door to investigate and found the door propped open by a rug. The strange noise revealed itself to be the air conditioning unit blowing into the facility while the front door was continually propped open. A search of the facility began and Resident #59 was discovered to be missing from the facility at 1:59 AM. The resident was located outside the facility on a different street than where the facility was located. The resident had been spotted by police and was returned to the facility accompanied by police at 2:20 AM. The resident's wheelchair was found outside, discarded by the resident under a nearby tree. The wheelchair did not have a wander guard unit attached to it. It was noted in the investigation that the wander guard alarm did not sound and that a single wander guard bracelet was found in a cup of water in Resident #59's room after the elopement. It was not clear if this bracelet had been on the resident's wrist or the resident's wheelchair. The resident was assessed by nursing upon return to the facility and by a physician later that morning and no injuries were noted as a result of this elopement. This review of the incident revealed that the facility reported this elopement to family, physician, county ombudsman, and state agency. Resident #59's medical record was reviewed on 7/31/19 at 11:48 AM. The review revealed an order dated 9/2/18 with the instructions, Resident with wander guard on at all times and was ordered to be performed every shift. This order was renewed on 9/17/18 with no additional instructions. Another order was found with the date 9/5/18 that stated, monitor target behaviors: non-compliance, argumentative, unsafe wandering, paranoia. Monitor every shift. The care plan topic of Falls was found dated 9/2/18 that stated, Resident is at risk for falling related to poor cognition and understanding of safety risks, that included the approach, Teach resident safety measures. Finally, an order for, Activities of Daily Living (ADL) wheelchair mobility: supervision was found dated 9/17/18, indicating that the resident required supervision when propelling himself/herself in a wheelchair. Ongoing review of the medical record revealed that, following the resident's elopement on 9/7/18, three care plan areas were initiated. The first, initiated on 9/7/18, was Ineffective coping related to situation crises, and included the approach, Assess if ineffective coping endangers the resident and/or others. Intervene as necessary. The second, initiated on 9/12/18, was Resident resists care related to not wearing cervical collar and not waiting for assistance with ambulation, and included the approach, Establish clear boundaries for the resident. The third, initiated on 9/17/18, was Elopement: Resident experiences wandering, and included the approaches, Equip resident with a device that alarms when wanders; check for proper functioning of device every shift, and, provide care, activities, and a daily schedule that resembles the resident's prior lifestyle. No care plan topic, assessment, or intervention was found that addressed the resident's ability to remove his/her wander guard bracelet. An interview was conducted with GNA #5 on 8/1/19 at 2:41 PM. During the interview, GNA #5 stated that she did recall Resident #59's elopement in the early morning of 10/4/2018. She confirmed that she observed the resident traveling in his/her wheelchair past the nurse's station in the Front Hall while GNA #5 completed documentation on the computer. When asked if she spoke with the resident, she stated, no, I didn't. She stated that Resident #59 would regularly travel the halls at night to get some coffee or talk to staff on the other unit, and that she didn't think anything of the resident passing by. GNA #5 recalled that only one wander guard unit could be found that night, but that it was found in a glass of water in the resident's room. When asked if the resident required supervision when moving about the facility via wheelchair, GNA #5 stated, No. Finally, when asked if any formal education had been provided to her following the incident, GNA stated that she had been asked to write a statement about the situation and some lessons were learned, but she stated that she had not received formal education following that elopement. When asked to elaborate on what 'some lessons' were, she stated, we just had to keep better eyes on him/her. An interview with the Quality Assurance and Performance Improvement (QAPI) Coordinator was performed on 7/31/19 at 3:07 PM. During the interview, the QAPI Coordinator stated that a Performance Improvement Project (PIP) had been performed by the facility regarding elopement that followed Resident #59's second elopement. The QAPI Coordinator stated, We thought one of the problems might be alarm fatigue. We also wondered if during the admission assessment, if they were capturing the elopement risk. We want to ask families about elopement risk and document events that lead to elopement like 'I want to go home.' We provided education to staff and wander guards are checked every day by nursing. So the four things we did were adjust the wander guard system to produce less false alarms on 10/11/2018, perform elopement risk assessment at admission, increase nursing documentation, and begin monthly tracking of elopement. We also began elopement drills and the first was done on 6/26/2019. The PIP materials were shared with the survey team at this time. The PIP documented the Date Identified as being 10/1/2018, although it can be seen that 10/16/18 was scratched out. The 'Goal / Objective' was, Resident Safety - Confused resident have supervision leaving building. The 'Issues Identified' was, 1) Bell / Alarm Fatigue - increased noise. 2) admission Assessment not triggering Risk of Elopement. The 'Actions' were, 1) Leadership meeting to discuss alarms - decrease sound frequency. 2) QA admission Elopement Risk. 3) Nursing document events possibly leading to increased elopement risk. 4) Monthly tracking elopement events - begin now. Due to the 'Date Identified' being documented as 10/1/2018, prior to Resident #59's elopement on 10/4/2018, the QAPI Coordinator was asked to clarify if this PIP was done in response to Resident #59's elopement or not. The QAPI Coordinator stated, yes, this was in response to Resident #59's elopement on 10/4/2018. The QAPI Coordinator could not identify any quality changes that were made as a result of the first elopement, however did state that she believed a second wander guard was placed on the resident after the first elopement. The QAPI Coordinator provided the survey team with a nursing note that had been written at the time of the first elopement that stated wander guards had been placed on both the resident's right wrist as well as on the resident's wheelchair. When asked how both wander guard bracelets were being tracked, the QAPI Coordinator could not provide any further documentation of how both were being tracked. 4) Interviews were performed with nursing staff including Licensed Practical Nurses (LPNs) #6, #8, and #12 as well as GNAs #2 and #5 on 7/31/2019 around 2:45 PM. Staff were interviewed on the units they were working on. All five staff were asked when they had most recently received elopement inservice training. None could recall when they had their most recent formal training but they did recall that an elopement drill had been performed in April, 2019. LPN #6 and #8 stated that the elopement training had gone well. Following her presentation of the elopement PIP on 7/31/2019 at 3:07 PM, the QAPI Coordinator was asked to provide any evidence of the staff education that she had indicated was given following Resident #59's second elopement. None was provided. An interview was performed on 8/1/19 at 9:00 AM with the Director of Nursing (DON), QAPI Coordinator, and Assistant Administrator. During the interview, it was asked if any education had been provided to facility staff following either of Resident #59's elopements. These facility staff stated that, because the resident did not leave facility grounds, they did not consider the events on 9/7/2018 to be an elopement and did not complete an incident report nor did they perform any staff education regarding the elopement. The DON was unsure at that time if staff education had been performed after Resident #59's second elopement on 10/4/2018. The survey team requested any education to be provided as soon as possible for review. The DON was asked again by the survey team on 8/1/2019 at 11:08 AM to provide any evidence of staff education following Resident #59's elopements. An 'Inservice Attendance Sheet' attached to the facility's elopement policy was given to the survey team at 12:05 PM. However, the date of the inservice was 4/16/2018 and 4/17/2018. 5) Review of the facility's investigation into Resident #59's second elopement revealed the statement, On 10-5-2018 an alarm was placed on front door. This alarm will be turned on each evening around 8 PM and turned off around 7 am. This alarm will be activated any time the door is opened during these hours. An observation of the front door alarm was made on 7/31/2019 at 1:55 PM. The alarm was a small white magnetized box that detected when the door was opened. It was found to make a chiming sound when the door was opened during the day although it could not distinguish if anyone walked through the door. Receptionist #7 was interviewed at the same time and she demonstrated the second, 'Alarm' setting by switching the setting on the white box. This setting made a louder, shriller tone that continued until the door closed. Receptionist #7 stated that the receptionists worked from 7:00 AM to 8:00 PM and that the front door was not monitored when a receptionist was not working. Receptionist #7 also said that the receptionists were responsible for switching the setting from Chime to Alarm each evening at 8:00 PM, as well as for disabling the handicap button that opens the front door automatically. Both are switched back when the receptionist arrives in the morning. Receptionist #7 also indicated that the wander guard alert system was a separate system and alarmed when a resident wearing a wander guard approached the front door. The facility's two nurses' stations were noted to be around 2 corners from the front door. It was noted that the front door alarm could be heard faintly from either nursing station while in both Chime and Alarm modes. However, there was no visual or auditory signal at either nurses' station when the front door alarm went off. The wander guard system was noted to create a local alarm and illuminate a light at both nurses' stations when it was activated. During an interview with the Acting Director of Maintenance that took place on 8/1/2019 at 12:57 PM, the Acting Director stated that the alarm on the front door was installed in March, 2019, five months after Resident #59's elopement on 10/4/2018. The Acting Director of Maintenance stated that he performs monthly reviews of the whole wander guard system to ensure that it is functioning correctly and that there have been no problems with it in either 2018 or 2019. The Acting Director of Maintenance clarified that his reviews involve verifying that the system alarms correctly when a wander guard unit is nearby. During a walk-through with the Administrator that took place on 8/2/2019 at 11:30 AM, the Administrator stated that there was another alarm system that hadn't been reviewed yet by the survey team. He referred to a House Alarm System (separate from the white front door alarm described above) that alarmed locally at the nurses' stations with sound and visual indicators when any of the external doors were opened. This was tested with an emergency exit at the end of the North Hall and it was confirmed that both sound and visual indicators activated at the nurses' station. The Administrator then stated this House Alarm system was also armed at the front door during the night. The walk-through continued to the front door where the Administrator indicated the keypad used to silence the wander guard system when it activated. The Administrator stated that this keypad was used to arm the front door with the House Alarm system each night. The receptionist, who was present at the time, then stated that she does not use that keypad to enable any house alarm. The Administrator then went to the Front Hall nurses' station and attempted to arm the House Alarm at the front door there. He was unable to do so but suggested that this is something that can be investigated. This House Alarm system was not enabled by the time surveyors exited the facility on 8/5/2019 at 12:00 PM, however the white Front Door Alarm and the wander guard systems were still functional. ~~ As a result of these findings, a state of immediate jeopardy was declared on 8/2/2019 at 10:50 AM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on 8/2/2019 at 1:18 PM and the State Agency was unable to accept this plan. The facility submitted additional plans at 2:45 PM, 4:21 PM, and 4:46 PM. The facility removal plan was accepted by the State Agency at 4:54 PM. The immediate jeopardy was removed on 8/5/2019 at 11:59 AM. The facility's abatement plan included the following provisions: - Facility staff to be immediately inserviced including nursing, administration, housekeeping, dietary, maintenance, and activities staff regarding the elopement policy, the wander guard policy, monitoring residents at risk for elopement, interventions to prevent elopement, and responding to alarms. This education will be performed by the Staff Development Nurse. - No staff can begin a shift without first receiving the above training. - A schedule will be maintained of all staff who have yet to receive training to ensure that they all receive the training as soon as is practicable. - A response log will be maintained at the front desk that staff must complete when they respond to the local alarm on the facility's front door. - Residents who are at risk for wandering will have a yellow wristband instead of a white wrist band. - Location checks will be performed every 30 minutes for 24 hours for residents after an elopement has occurred. - Care plans will be updated after an elopement to reflect any new interventions. - Alleged date of compliance: 8/4/2019.