**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number M100131450. PNC was accepted for this citation. Based on observation, interview and record review, the facility failed to provide adequate supervision for one resident (R81) of six residents reviewed for elopement by allowing the resident, who was severely cognitively impaired, ambulatory and identified as an elopement risk, to exit the building unbeknownst to facility staff while wearing a Wanderguard bracelet, including use of an alarmed elevator and exiting an alarmed door between approximately 9:15 PM - 9:25 PM on 08/07/2022. This deficient practice resulted in the likelihood of serious injury or death from being unsupervised outside in the dark near a busy four-lane road in the parking lot of a business adjacent to the facility. R81 was returned to the facility, escorted by an agency staff member who located the resident while on their way into work on 08/07/2022 at approximately 9:35 PM - 9:45 PM. Immediate Jeopardy: The Immediate Jeopardy (IJ) started on 08/07/22 and the immediacy was removed 08/07/22 per review of the facility's responding interventions and associated staff education completed on 08/12/22 and verified on 02/28/2023. The IJ was identified on 02/28/23 during the recertification survey. The facility's Nursing Home Administrator (NHA) was notified of the IJ on 02/28/23 at 9:10 AM and was asked for an abatement plan. The IJ was removed on 08/07/2022, based on the facility's implementation of the abatement plan as verified onsite on 02/28/23. Findings include: Resident #81 (R81): Review of the facility record for R81 revealed an admission date of 5/29/22 with diagnoses that included dementia with behavioral disturbance, history of traumatic brain injury, metabolic encephalopathy, Anxiety disorder, history of repeated falls, difficulty in walking, generalized muscle weakness and vertigo. Minimum Data Set (MDS) assessment dated [DATE] revealed Brief Interview of Mental Status (BIMS) score of 0 which indicated severe cognitive impairment and functional assessment section GG indicated R81 required maximum assistance for Activities of Daily Living (ADL) and that the ability to walk ten feet was not assessed due to medical or safety concerns. Despite the lack of walking assessment in the MDS, R81's record revealed that, at the time of the reported elopement, R81 routinely ambulated without physical assistance or use of an assistive device. Supervision was required due to instability and a history of repeated falls in addition to the supervision recommended due to the elopement risk. Review of the facility form Risk for Elopement - V2 for R81, dated 6/13/22, included Question #2. Does the [R81's] wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility)? The response to this question is documented as Yes. R81 is identified on the Resident Elopement Risk grid as being recommended for and provided with a WanderGuard on the left wrist. Review of R81's care plan with a revision date of 5/30/22 revealed a Focus area that stated [R81] is at risk for elopement related to cognitive impairment/Dementia with behavior and wandering. The Goal associated with this Focus area stated [R81] will not leave the facility unattended through the review date (8/29/22). Interventions associated with this goal included: Observe wandering behavior and attempt diversional interventions when wandering into inappropriate locations such as attempts at exiting facility and Distract resident when wandering into inappropriate areas by offering pleasant diversions, structured activities, food, conversation, etc. On 2/27/23 at 11:50 AM, R81's family member and Responsible Party Q was interviewed via a telephone call. They were able to recall the incident during which R81 eloped on 8/7/22. Q reported that they were contacted by the facility shortly after R81 was returned to the facility and assessed. Q stated They told me they looked at the camera but did not provide an explanation of how R81 was able to exit the building undetected. Q expressed concern that they had not been contacted prior to R81 being located however they later realized that nobody was aware R81 was missing until they were located off the facility property. Q expressed that they still don't understand how R81 was able to exit due to having a WanderGuard and being on the second floor but that they are not overly concerned regarding further elopement as R81 is no longer ambulatory. On 2/27/23 at 10:59 AM, RN A was interviewed via a telephone call. RN A reported that they did recall the elopement incident on 8/7/22 involving R 81 and that they were working on the unit and assigned to R81 during the time of the incident. They recalled being at the nurses' station completing documentation and R81 walking past. RN A recalled hearing R81 interacting with other staff down the hallway out of sight and stated that what they recall as being approximately 15 minutes later being called by licensed practical nurse (LPN) T from the first floor who reported that R81 was being brought into the facility by a certified nurse aide (CNA) who found her in front of the hookah shop next door. Registered Nurse (RN) A reported being involved in completing R81's wellness assessment and contacting management and R81's family member Q regarding the incident. Regarding the possible means of R81 being able to exit the facility, RN A reported that they do not recall ever hearing an alarm and was not sure how R81 was able to exit. RN A reported that management had reported that the exit of R81 was viewed on the facility's CCTV (video) footage. RN A reported having four CNA's working on the 2nd floor that evening which was considered adequate as the normal CNA staffing for the floor was four to five CNA's. On 2/27/23 at 11:35 AM, CNA G was interviewed in the facility and reported that they recalled the incident on 8/7/22 when R81 eloped. CNA G stated they were assigned to the second floor during that shift and reported not being able to recall seeing R81 near the time of the elopement and that they were not aware of the situation until staff were notified that R81 had been returned to the building from near the business next door. CNA G did not recall hearing any alarms around the time of the incident. On 2/27/23 at 12:15 PM, CNA R who was listed as having worked second shift on the second floor the evening of 8/7/22 was interviewed via telephone and reported vaguely recalling the incident of R81's elopement but stated that they could not recall any details of the incident. On 2/27/23 at 1:30 PM, CNA S, who was identified as the agency CNA who found R81 at the business next to the facility, was interviewed by telephone. CNA S reported that they recalled the evening of R81's elopement. CNA S reported that their family member was driving them to work and had accidentally passed the facility. As they turned around in the plaza next to the facility the family member noticed R81 in front of the hookah shop and expressed concern as they noticed R81 did not have shoes on. CNA S reported that they did not know or recognize R81 as they normally did not work on the second floor. CNA S reported that they pulled up to check on the person thinking that it could be a resident and there was a man nearby. When they exited the vehicle CNA S reported that the man was stating that he was going to call the police if someone did not deal with the person [R81] as they were attempting to enter the hookah shop when it was closed. CNA S reported that they walked to the facility while their family member watched R 81 and found LPN T who returned to the parking lot with them and verified that the person was R81 and was a resident of the facility. CNA S reported that when they attempted to walk toward the facility R81 was walking gingerly as if their feet were hurting and therefore they decided to assist R81 into the vehicle and drive them next door to the facility. CNA S reported that when this occurred it was dark outside and as they usually arrived early for their shift, they felt that this incident occurred at approximately 10 PM however they were not sure exactly what time it was. Review of the facility time card for 8/7/22 for CNA S revealed a punch in time of 10 PM for a scheduled 11 PM start. On 2/27/23 at 2:15 PM, CNA P who was identified as working on the second floor during the shift of R81's elopement was interviewed in the facility. CNA P recalled the incident and reported being unable to recall any specifics other than being made aware of the incident after R81 had been returned to the facility. CNA P could not recall hearing any alarms around the time of the incident and stated I would've responded to an alarm if I heard it. On 2/27/23 at 2:32 PM, the Facility Administrator (NHA) was interviewed regarding R81's elopement on 8/7/22 and the corresponding Facility Reported Incident (FRI) report. In summarizing the incident the NHA reported that when R81 exited the building they were noticed and brought in by a CNA who was on shift and was outside taking a break. The NHA reported that there was video footage of the incident that contributed to the timeline of events described in the FRI however the footage had been subsequently lost due to a power failure. The NHA provided a walk-through demonstrating the reported route of R81's elopement and indicated that at the point of exit a staff member/s had responded to the exit door alarm however they were not able to recall who the staff member/s were and no such person was identified in the FRI. On 2/28/23 at 3:05 PM, LPN T was interviewed by phone. LPN T reported that they recalled the incident of R81 eloping on 8/7/22. LPN T stated that an agency CNA entered the building and reported that they thought a resident may be at the hookah shop next door and asked if LPN T could come next door to verify if the person was a resident. T agreed to walk next door and did verify that R81 was the person in front of the hookah shop. LPN T reported that they assisted R81 into the CNA's vehicle so that R81 did not have to walk in her socks and they pulled up to the front entrance and assisted R81 into the building and back to the second floor where R81's nurse, Nurse A, began to assess the resident. LPN T reported that prior to and during the time of this incident they were working on the first floor and did not hear any type of an alarm and had not been aware of a missing resident. On 2/28/23 at 11:51 AM, The facility Director of Nursing (DON) was interviewed and reported that the expectation regarding residents who are at risk for elopement is that staff provide supervision and respond immediately to the elevator and door alarms and follow the protocol for locating any missing residents. On 2/28/23 at 1:40 PM, The NHA reported that the expectation for supervision of residents identified as an elopement risk is that staff provide consistent and regular checks/supervision to verify the residents whereabouts. Review of the facility Elopement Policy with the most recent effective date of 5/1/22 revealed the general policy statement It is the policy of this facility to prevent to the extent reasonably possible, the elopement of guests/residents from the facility. This policy further defines elopement as occurs when a guest/resident who needs supervision leaves a safe area without authorization and/or any necessary supervision to do so. This policy also states in item C under Procedure and regarding WanderGuards that Verification of unit functionality will be tested by the midnight shift licensed nurse using wandering testing device and documented on the guest/residents MAR. Review of the MAR for R81 in the section Confirm that WanderGuard on resident is functioning appropriately. Left wrist. is marked N for No on the dates of 8/7/22 and 8/8/22. F-689 Abatement Plan February 28, 2023 Identification of Residents Affected or Likely to be Affected: (R81) There have been no further admissions and no current residents with Elopement since 08/07/2022. Actions to Prevent Occurrence/Recurrence: 1. The facility immediately placed Resident #81 on a 1:1 monitoring/supervision. 2. Immediate door checks were made on 08/07/2022 at 11:30 pm by maintenance staff. 3. Staff who were present in the building were educated on timely response to alarms and the elopement protocol. 4. Nurses reviewed the elopement books and ensured that residents who were on elopement protocols had functioning bracelets and the book was up to date. 5. Internal head count for correct census completed. 6. Administrator, DON and Responsible Party were immediately notified. Admin on site and physician and family alerted