**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, review of facility surveillance camera footage, and interviews, for one of three sampled residents (Resident #1) who had a history of being homeless, required hospitalization after sustaining a Traumatic Brain Injury (TBI) due to a fall, and had a Temporary Guardianship in place, the Facility failed to ensure he/she was assessed for risk of elopement and that he/she was provided with adequate supervision to maintain his/her safety to prevent an incident of elopement, when he/she was able to walk out of and away the facility past multiple staff members who were assigned to monitor visitors and residents entering and leaving through the front entrance of the facility. On 11/27/22, at approximately 12:30 P.M., Resident #1 left his/her unit by getting on the elevator across from the nursing station and did so unnoticed by staff members that were in the area at that time. Resident #1 exited the elevator on the first floor, made his/her way to the main lobby, and despite facility policy that all visitors must stop at the reception desk to sign in and out of the facility, Resident #1 was able to walk undetected past the receptionist and a security guard, who were assigned to and stationed in the front lobby, and made his/her way out the front door. Resident #1 exited the facility to the outside patio smoking area located at the front of building, where several residents were attending a scheduled supervised smoking break, which was being supervised by another security guard and the smoking attendant. Resident #1 stood outside against one of the patio railings for several minutes, and although both staff members recall seeing Resident #1 outside that day, neither of them approached or questioned him/her. Resident #1 walked down the front stairs, stopped looked back at staff briefly, and then walked away from the facility. Resident #1 was not noted to be missing by staff until 4:00 P.M., (three and a half hours later). Resident #1's whereabouts are still unknown. Findings include: The Facility's Policy, Elopement, dated 7/2015, indicated that all residents are screened for risk of elopement on admission by the Licensed Nurse. The policy defined elopement as the ability of a resident who is not capable of protecting himself/herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way. The Facility's Policy, Leave of Absence (LOA), dated 12/2015, indicated that a physician's order is required for a resident LOA. When the resident is their own responsible person, they may go on LOA unattended. When the resident is not their own responsible person, a responsible person is required to attend the LOA. Residents and responsible persons are required to sign out/in on the LOA log. The Facility's Policy, Visitors Policy, undated, indicated that all visitors must enter the facility through the main entrance. All visitors must register their name, the name of the resident they are visiting and the time of day they enter and leave the facility. The Policy indicated that the guest register is located at the reception desk. The Policy indicated that Visitor badges will be provided to guests by the receptionist and must be worn during the visit, and that visitors may be asked to provide identification. Review of the report submitted by the facility via the Health Care Facility Reporting System (HCFRS), dated 11/29/22, indicated that on 11/27/22 at 4:00 P.M. the nursing supervisor noted that Resident #1 was not in his/her room, was not on his/her unit, Doctor Hunt (facility's missing resident protocol) search was initiated, calls were placed to local hospital emergency departments and Resident #1 had not checked in there, local police, the Nurse Practitioner, his/her Guardian, and facility administrative staff were notified. Police arrived to the facility at 5:30 P.M., report given, Resident #1 has no family contact, is homeless, and does not have an address at this time. The Report indicated Resident #1 had recently been admitted to the facility after an acute hospitalization after he/she had a fall down 14 stairs, with resulting subdural hematoma (bleeding, collection of blood associated with a traumatic brain injury) was without consciousness, and had hemorrhagic contusions with scattered focal fractures. Resident #1 was admitted to the facility in November 2022, diagnoses included traumatic subdural hemorrhage/hematoma (head injury strong enough to burst blood vessels) with resulting cerebral infarct (ischemic stroke) and expressive aphasia (affects speech, as well as writing and understanding spoken/written language), right sided skull and facial fractures, Substance Use Disorder (SUD, related to alcohol abuse) and history of homelessness. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that during his/her hospital admission, he/she was determined to be incapacitated and the hospital sought and obtained a court order for Temporary Guardianship. Review of Resident #1's Temporary Guardianship, dated 11/16/22 indicated the resident had acute care needs that required immediate attention, therefore the Guardian was authorized to admit Resident #1 to a nursing facility, apply for health insurance benefits, obtain financial information and authorize an antipsychotic medication treatment plan. The Temporary Guardianship is in place for a period of 90 days, through 2/15/23. Review of Resident #1's Nursing admission assessment dated [DATE] at 5:40 P.M. indicated he/she was alert to person, but not to place or time. Further review of Resident #1's Nursing admission Assessment indicated that (despite facility policy that all residents will be assessed upon admission) an Elopement Risk Assessment was not completed upon admission for Resident #1 at any time during his/her admission. Review of Resident #1's Certified Nurse Aide (CNA) Resident Care Card, undated, indicated Resident #1 required continual supervision with ambulation. During an interview on 12/12/22 at 12:37 P.M., Nurse #2 said she completed Resident #1's admission assessments but said she did not complete an Elopement Risk Assessment for him/her on the day of admission. Nurse #2 said an Elopement Assessment should be completed within 1 to 2 days of a resident's admission. During an interview on 12/06/22, the Director of Nursing said Elopement Risk Assessments are to be completed on admission by the admitting nurse. During an interview on 12/07/22 at 9:15 A.M., the Regional Social Worker (SW) said facility policy is that all new admissions are reviewed the next business day at morning meeting. The SW said for new admissions they would review the hospital transfer documentation, and an incapacitated resident would be identified on admission. During an interview on 12/06/22 at 11:48 A.M., the SUD (Substance Use Disorders) Councilor said he had not met Resident #1 due to the Holiday. The SUD Councilor said the admitting Nurse completes the initial SUD/ETOH (alcohol) assessment, and that they look for behaviors in the discharge paperwork that could be a red flag. The SUD Councilor said he likes to assess SUD residents within 48 hours of admission, but that Resident #1 had eloped prior to him being able to complete the assessment. There was no documentation to support an Elopement Risk assessment was ever completed by the facility for Resident #1, who still had a Temporary Guardianship in place due to incapacity related to his/her TBI, who was homeless with no known address, and had no involvement or contact with family for support in the community. Review of Resident #1's Nursing Progress Note dated, 11/27/22 at 4:00 P.M., indicated Resident #1 was not in his/her room and that Doctor Hunt (facility's missing resident protocol) was initiated. The Note indicated the Administrator, Director of Nurses, Guardian, Police and local hospitals were notified of the missing resident. During the dates of survey, the surveyors made the following observations of the facility's main entrance, lobby area, and outdoor smoking area (patio) that is directly off the main entrance. The lobby was observed to be approximately 12 feet (ft) x 12 ft, and was a very small, enclosed area, so anyone coming and going through the lobby, including in or out the front door, would be seen by staff seated in the lobby. There is a Security Guard desk equipped with a security camera monitor, and another desk adjacent to the Security Guard for the Receptionist, where visitors and vendors are instructed to stop to sign in and out of the facility. There was another door a few feet away from the Reception Desk that enters onto the first floor. There are no resident rooms on the first floor. The elevators on the first floor are located beyond the lobby area down a hallway and are not in view of staff stationed in the lobby. Review of surveillance camera video footage provided by the facility, indicated the timeline and sequence of Resident #1's elopement on 11/27/22 were as follows: -12:31 P.M., Resident #1 comes out of his/her room into the hallway on the 5th Floor and makes his/her way to the area close to the nursing station. Resident #1 is dressed in a long-sleeved shirt and khaki pants, and places a suit jacket on a chair in the hallway. A nurse and a certified nurse aide (CNA) can be seen in the area around the nursing station, but do not appear to notice or acknowledge Resident #1's presence. Resident #1 has full view and easy access to the unit two elevators that are now in front of him/her. A food truck had also been delivered and left on the unit, and obscures the 5th floor unit camera's view of the elevators. -12:32 P.M., Resident #1 walks toward the elevators, then turns back toward the chair where he/she left the jacket, he/she picks it up, and then walks in a hurried manner towards the elevators. Resident #1 is no longer in view of the 5th floor camera at this point. The next time surveillance camera footage (no time stamp available) shows Resident #1 as he/she is exiting the building through the main entrance front door that leads directly to the designated smoking area in the front of the building. Resident #1 can be seen dressed in a long sleeve shirt, khaki pants, sneakers, with his/her right hand in his/her suit jacket pocket, he/she was not observed to be on a cell phone at that time. Once Resident #1 exited the elevator on the 1st floor and made his/her way down the hallway to get to the lobby, once in the lobby he/she would have to walk past the receptionist and the security guard stationed in the front lobby in order to get to and go out through the main entrance. Surveillance camera footage then shows Resident #1 as he/she walks over to the exterior main entrance stairs and leans against the railing. There is another resident in view of the camera sitting to the left of where Resident #1 was standing at the top of the stairs. Resident #1 walks down the stairs, stops, and while facing the street, he/she appears to be looking for something in his/her clothing. Resident #1 pulls out a cell phone from the left back pocket of his/her pants and then appears to be speaking on the phone. Resident #1 proceeds to walk over a grassy area next to the stairs while holding the phone in his/her right hand and then steps onto the sidewalk. Resident #1 can be seen on the camera footage running away from the facility. -12:37 P.M., Resident #1 can be seen on another external facility surveillance camera walking on the sidewalk, away from the facility with his/her cell phone in his/her right hand holding it to his/her right ear. - 12:39 P.M. is the last time Resident #1 is seen on surveillance camera footage, he/she is walking down the hill away from the facility and looking at his/her cell phone. Review of the surveillance camera footage from 12:33 P.M. to 12:39 P.M., indicated that the Smoking Attendant and Security Guard, assigned to supervise the residents attending the 12:30 P.M. to 1:15 P.M., scheduled smoking break do not come into the view of the cameras, so their exact locations or what they are doing on the patio are not captured or recorded. Surveillance camera footage was reviewed multiple times by the surveyors, and there was no surveillance camera footage that showed or supported that Resident #1 was ever approached, questioned, or stopped by staff members at any point on the day he/she eloped from the facility. During an interview on 12/07/22 at 11:37 A.M., Security Guard (SG) #2 said he was on duty 11/27/22 for the day shift. Security Guard #2 said he could not recall if he was stationed in the lobby area or out in the smoking area during the smoking break that started at 12:30 P.M. SG #2 said prior to Resident #1's elopement that day, the LOA Book had not been updated regularly. SG #2 said on 11/27/22, he did see, but did not recognize the person (Resident #1) leaving the facility as a resident. SG #2 said he can only assume that the person (Resident #1) appeared to be a visitor when he/she left the facility, but said he did not observe the person (Resident #1) sign in or out with the receptionist. SG #2 and said although he saw him/her, said he did not stop the person (Resident #1) to question him/her, but should have. During an interview on 12/07/22 at 11:10 A.M., Security Guard (SG) #1 said she was on duty 11/27/22 during the day shift, and was assigned to cover the front lobby area. SG #1 said all visitors are required to stop at the reception desk in the lobby to sign in/out and receive a visitor sticker upon entering. SG #1 said she did not see Resident #1 enter the building or sign in as a visitor that day. SG #1 said although she was assigned to cover the lobby that day, said she did not see Resident #1 leave the facility that day. Although SG #2 said he assumed the person (Resident #1) he observed on 11/27/22 out in the smoking area and then leaving facility grounds during the smoking break was a visitor, there was also no documentation to support that the person (Resident #1) signed into the visitor log or was stopped in the lobby by staff to sign out of the facility that day, as a visitor. During an interview 12/07/22 at 3:20 P.M., Nurse #1 said she was the Nursing Supervisor on duty 11/26/22 and 11/27/22. Nurse #1 said she had met Resident #1 on 11/26/22, he/she was quiet and kept to him/herself. Nurse #1 said on 11/27/22, she worked as a staff nurse on Resident #1's unit and after completing her medication pass on the day shift, she did rounds on the unit before going to another floor for the next shift. Nurse #1 said that was when she noticed Resident #1 was not in his/her room and asked other staff members if they had seen him/her. Nurse #1 said they started looking throughout the unit, including in the closets, and community rooms without success. Nurse #1 said Security was notified and they said they had not seen Resident #1. Nurse #1 said other residents reported to staff that they had seen Resident #1 outside in the smoking area talking on the phone. Nurse #1 said Dr Hunt was initiated at 4:00 P.M. The Administrator, Director of Nurses, the physician, local Police and Resident #1's Guardian were notified. Nurse #1 said Resident #1 was still missing when she completed her shift at 11:00 P.M. During an interview on 12/07/22 at 3:02 P.M., The Smoking Aide said she was working on 11/27/22, and did see a person (later identified to be Resident #1) in a suit jacket standing near the stairs talking on the phone, but said she did not know he/she was a resident. Smoking Aide said she was only responsible to supervise residents who are out there to smoke. During an interview on 12/06/22 at 9:30 A.M., the Administrator said that Resident #1 was admitted to the facility 11/23/22 and eloped on 11/27/22 at 12:30 P.M. The Administrator said they reviewed the surveillance camera video footage to determine how Resident #1 managed to elope that day. The Administrator said watching the video of the incident, Resident #1 presented like a visitor when exiting the facility. The Administrator said there was a receptionist and a security guard assigned to and stationed in the lobby on 11/27/22 at the time of Resident #1's elopement. The Administrator said Resident #1 should have been stopped by the receptionist or security guard before exiting the facility, as a resident or visitor, according to facility policy. On 12/07/22 the facility provided the surveyors with an acceptable plan of correction that addressed the identified area of concern. The plan of correction included the following: A. 11/27/22, Facility and ground search conducted for Resident #1, local police, hospitals, and Temporary Guardian notified. B. 11/28/22, Facility initiated Nursing Rounds, all nurses must conduct a room by room search at the start of each shift and ensure they have visual contact with all residents they are assigned to care for. C. 11/27/22 and 11/28/22, Nursing Supervisors and Nursing Management staff completed audits on all resident records to ensure Elopement Risk Assessments were completed and accurate. D. 11/28/22 through 11/30/22, Nursing Supervisors and Nursing Management completed resident record audits to ensure baseline care plans were in place, and that comprehensive care plans were updated as needed. E. 11/27/22 and 11/28/22, Nursing Supervisors and Nursing Management staff reviewed care plans and care cards for all residents assessed for and identified as being at risk for elopement and were updated as needed. F. 11/28/22 and 11/29/22, Administrative staff provided education and training to Receptionist(s), and staff assigned as smoking attendant regarding visitations, elopements, and supervision of residents. G. 11/27/22, immediate change,Security Guards, Receptionist, and Smoking Attendants to review Elopement Book at the start of each shift for any updates. H. 11/27/22 through 11/30/22, Staff Education Coordinator (SDC) and Management reviewed the Elopement Policy, which included the 5 Eyes of Elopement with all staff and immediate actions to be taken by staff in the event of a missing resident. SDC provided staff education related to Identifying resident risky behaviors for elopement is key. I. 11/28/22 through 11/30/22, Staff Education Coordinator and Nursing Management team completed education for nursing staff on identifying, reporting, and documenting when a resident exhibits risky behavior, which included observations and a list of potentially risky behaviors. J. 11/28/22 through 11/30/22, Staff Education Coordinator and Nursing Management team provided education to nursing staff regarding reviewing and being aware of changes in residents plans of care, safety measures, and K. 11/30/22, Main Entrance Security Change, a new keypad lock installed on front door, anyone wishing to enter or exit the facility (residents, staff, visitors) can only do so by first being screened by security guards. Security Guards are assigned to the facility 24/7. L. Facility QAPI Committee meeting to include and continue to review concerns identified related to resident safety, security, elopement risks, and resident assessments. M. The Administrator, Director of Nursing, and/or their designees will be responsible for overall compliance.