**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 178 NAC 12-006.09(I) Based on interview, observation, and record review, the facility staff failed to evaluate and implement interventions to prevent elopement for 2 (Resident 1 and 4) of 4 residents sampled. The facility identified a census of 44. Findings are: Record review of Facility policy dated 10/2024 revealed the following: -Elopement is a situation where an unsupervised resident is found outside of the facility. Staff is unaware of the resident's departure (did not visually see the resident leave). -Policy -It is the policy of the facility to take proper preventative measures to prevent episodes of resident wandering from the facility and to locate resident in an expedient and timely manner. -Procedure-Elopement I. Preventative measures will be taken by the facility to prevent residents from elopement. A. Assessing all residents upon admission for the potential of exit seeking. An Elopement Risk Assessment will be completed on each resident on pre-admission/admission, quarterly and on change of condition if they display behavior changes that may indicate a risk for exit seeking. B. Interventions are placed on the Resident's Care Plan. C. Wander guard bracelets (a device worn by residents who wander that will, if too close to an exit door, will lock the exit door and sound an alarm to alert facility staff) will be placed on Resident that are identified as Exit Seekers. D. Ongoing documentation by the night charge nurse that the wander bracelets on residents are functioning and documenting such on the Medical Administration Record (MAR). E. Ongoing documentation by the Maintenance Director that the wander guard door signaling devices are tested on e time a week and the door alarms are tested on a weekly basis. F. Family will be instructed upon admission about the need to sign in and out at the nurse's station when taking the resident out of the facility. G. A photograph will be taken of each resident upon admission and updated as resident's physical appearance changes. H. Doors will be alarmed at all times with the exception of the Front Door during normal visiting hours. II. If an employee observes a resident leaving the premises, he/she should: A. Attempt to prevent the departure in a courteous manner. B. Get help from other staff members in the immediate vicinity. C. Instruct another staff member to inform the Charge Nurse of Director of Nursing that resident has left the premises. III. When an employee discovers that a resident is missing from the facility: A. Notify the Charge Nurse B. Initiate a search of the building and the premises. C. Notify Director of Nursing and/or Administrator or their designees. D. Initiate an extensive search of the surrounding area. IV. When a departing individual returns to the facility: A. In case of an Elopement the Charge Nurse or designated staff member will complete the Incident Report Form. B. Notify the attending Physician. C. Notify the resident's legal representative of the incident. D. Notify Director of Nursing and/or Administrator or designees. E. On direction of above notify Health and Human Services/Adult Protective Services. F. All pertinent information will be charted in departmental notes. G. Administration may discuss additional safety measures such as wander guard placement; room move or alternative facility placement. A. Record review of Resident 1's Census Sheet revealed the resident was admitted to the facility on [DATE]. Record review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) dated 9/3/2024 revealed Resident 1 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) with a score of 1. A BIMS score of 1 indicated the resident was severely cognitively impaired. The functional status of Resident 1 was assessed as eating required set-up or clean up assist, toileting and bed mobility required partial/moderate assistance, and transfers required substantial/maximum assist. The mobility devices used by Resident 1 was identified as using a wheelchair. Resident 1's active diagnosis included: Progressive neurological conditions, diabetes, respiratory failure, altered mental status, and atrial fibrillation. Resident 1 also received Hospice Care (an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and terminal illnesses). Record review of Resident 1 Care Plan (CP) dated 10/14/2024 identified a focus of The resident has impaired cognitive function/dementia or impaired thought processes related to dementia. The goal of the focus is Resident will remain safe in the facility despite wandering behaviors secondary to dementia diagnosis by next review on 10/16/2024. The interventions were identified as the following: 1. Ask yes/no questions to determine the resident's needs. 2. Cue, reorient and supervise as needed. 3. Discuss concerns about confusion, disease process, nursing home placement with resident/family/caregivers). 4. Give resident puzzles, crafts, and activities to keep his hands busy to help prevent him from fiddling with his dentures. 5. The resident is able to: self-propel around the unit. Resident prefers not to wear the Wander guard on wrist. Placed on the wheelchair due to irritation and discomfort. Record review of Resident 1's Elopement Risk Tool (ERT) dated 5/21/24 revealed Resident 1 had been found to be at risk for elopement. According to the ERT dated 5/21/2024 Resident 1 cognition had declined since being on hospice and a wander guard was placed. Record review of a facility Investigation report (IR) dated 9/05/2024 revealed Resident 1 was found in the facility parking lot by staff as they were leaving on 8/30/2024. According to the IR dated 9/05/2024 a Wander guard was in place and did not alarm when Resident 1 left. The intervention put into place to prevent re-occurrence was to place the Wander guard in a new location on Resident 1's wheelchair. In addition staff were to check the whereabouts of Resident 1 at shift change and to re-direct the resident into the commons area. Record review of a IR dated 10/16/2024 revealed on 10/13/2024 the Assisted Living staff notified the facility Charge Nurse Resident 1 was lying on the ground in the driveway. According to the IR dated 10/16/2024 Resident 1 required medical attention and was transported to the hospital. Further review of the IR dated 10/16/2024 Resident 1 sustained multiple small subdural brain bleeds, right sided rib fracture and a pelvis fracture and there was no witnesses. Record review of Resident 1's Hospital admission records dated 10/13/2024 revealed under the Consult orders section of the report revealed Resident 1 had a small subdural hematoma ( a collection of blood between the covering of the brain and its outermost covering). Record review of a information sheet from the hospital printed on 10/14/2024 for Resident 1 identifed the reason Resident 1 hospitalization was a fracture of Pubic Rami (pelvis area), Head injury and multiple rib fractures. Record review of Resident 1's Progress note dated 10/14/2024 revealed Resident 1 returned to the facility with the diagnosis of a closed fracture of multiple of Pubic Rami, Right Head injury and multiple right side rib fractures. On 10/17/2024 at 11:24 AM an interview was conducted with the facility Administrator. During the interview the facility Administrator reported Resident 1 did not have have the wander guard on the wheelchair or their person when Resident 1 was found. The Administrator further reported hospice personal brought in a new wheelchair on 10/12/2024 and the Wander guard was not transferred to the new wheelchair. A interview with Assistant Director of Nursing (ADON) at 3:10 PM revealed the ADON reported Resident 1 wasn't getting up out of bed currently, staff were to keep Resident 1 comfortable due to their injuries. B. Record review of Resident 4's quarterly MDS dated [DATE] revealed an admission date of 1/6/24 and diagnoses that included Alzheimer's Disease, Non - Alzheimer's Dementia, Anxiety and Depression. The MDS identified that Resident 3 had a BIMS score of 4, which indicated severe cognitive impairment, no wandering behaviors exhibited, manual wheelchair use, no impairment in range of motion of upper or lower extremities and independence with locomotion once in the wheelchair. Record review of Resident 4's Care Plan dated 1/8/24 revealed a concern related to the risk of elopement as evidenced by exit seeking behaviors, disorientation to surroundings, agitation, anxiety, wandering and verbalizing intent to leave. The care plan included no updates or revisions to the care plan related to elopement risk until 10/14/24. Interventions included: - 1/8/24: Elopement risk assessment quarterly and PRN [as needed] - 1/8/24: Place a wander guard on me, please check to make sure it is functioning correctly per facility protocol. - 10/14/24: Check wander guard for proper functioning. Record review of Resident 4's Elopement Risk Tool dated 1/24/24 revealed that the resident had been found to be at risk for elopement. Record review of a facility investigation dated 6/25/24 revealed that Resident 4 had eloped from the facility on 6/19/24 to the assisted living side of the building. The investigative report revealed that the alarms were intact and functional and going off at the time of the elopement. The facility investigation revealed that the residents care plan was updated to include walking rounds to be completed at each shift change due to wandering behaviors and resident was to be escorted by staff to every meal by wheelchair. Record review of Resident 4's Electronic Medical Record revealed no elopement risk assessments had been completed quarterly after 1/24/24 and a risk assessment had not been completed after the elopement on 6/19/24 as per the facility policy. Record review of Resident 4's CP revealed no new interventions related to elopement had been identified in the care plan for Resident 4 after the elopement on 6/19/24. Record review of Resident 4's TAR dated June 2024 revealed an order to check the wander guard for proper functioning (on wheelchair) was started on 5/28/24. Record review of Resident 4's TAR's dated June 2024, August 2024, [DATE] and October 2024 revealed missing documentation of the monitoring of the wander guard on the following dates: - June 2024: 6/1, 6/2, 6/3 - August 2024: 8/1, 8/2, 8/18, 8/19, 8/23, 8/27, 8/28, 8/30 - September 2024: 9/8, 9/9, 9/20, 9/28, 9/29 - October 2024: 10/8 Observation on 10/17/24 at 8:25 AM: revealed Resident 4 seated in a wheelchair in the main dining room. A wander guard was attached to the left leg of the wheelchair with a replacement date of 11/15/ 25 written on the wander guard. Interview on 10/17/24 at 1:30 PM with the ADON confirmed that documentation on the TAR for checking of the wander guards was missing on the above cited dates. The ADON was unable to confirm that monitoring had been completed on those dates. The ADON confirmed that no elopement risk assessment had been completed after the elopement on 6/19/24 in accordance with the policy. The ADON confirmed that no quarterly elopement assessments had been completed since 1/24/24.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, record review and interview; the facility failed to evaluate Resident 1's risk for hot liquid burns which resulted in a burn from a hot coffee spill. A total of 3 residents were reviewed for burn risk. The facility census was 38. Findings are: Record review of a facility policy entitled Hot Liquid Safety dated 6/2024 revealed the following: -Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions. -Definitions: - Proper (safe and appetizing) temperature: means both appetizing to the resident and minimize the risk for scalding burns. - Scalding is a burn caused by spills, immersion, splashes, or contact with hot water, food and hot beverages, or steam. 1. Hot Liquids can cause scalding and burns. The degree of injury depends on the temperature, the amount of skin exposed and the duration of the exposure. Refer to the table attached to this policy for an illustration of the time required for a burn to occur at various temperatures. 2. The temperature of the hot liquids will be checked in the dietary department prior to serving. If the temperature is greater than 140 degrees Fahrenheit, hold the liquid in the dietary department until it reaches the appropriate temperature. 3. All residents are assessed for their ability to handle containers and consume hot liquids. Residents with difficulties will receive appropriate supervision and use of assistive devices in order to consume hot liquids. Interventions will be individualized and noted on the care plan. Interventions include but are not limited to: a. wide based cups b. Cups with lids and handles c. Limit Styrofoam cups to residents with no difficulties. d. Aprons e. Disallow hot liquids while lying in bed. 4. Staff shall respond immediately to spills or other accidents with hot liquids to minimize the risk for burns. Follow procedures regarding incidents / accidents should anyone experience exposure to hot liquids. 5. Monitor residents for at least 24 hours following exposure to hot liquids, as redness or blisters may not appear initially. 6. General safety precautions when serving hot liquids include , but are not limited to: a. Make sure resident is alert and proper positioning to consume hot liquids. b. Use cups, mugs, or other containers that are appropriate for hot beverages. c. Do not overfill containers. d. Regulate temperature of hot liquids to which residents have direct access. e. Place filled containers directly on table. Do not hand them directly to the residents. f. Keep hot liquids away from the edges of the table. g. Do not refill containers while the resident is holding onto the container. -Time and Temperature relationship to Serious Burns 155 degrees 1 second 148 degrees 2 seconds 140 degrees 5 seconds 133 degrees 15 seconds 127 degrees 1 minute 124 degrees 3 minutes 120 degrees 5 minutes. The facility policy Hot Liquid Safety was updated in July of 2024 after Resident 1 experienced a hot coffee burn. The policy was revised to read: 3. All residents will be assessed for their ability to handle containers and consume hot liquids on admission, and per MDS schedule. B. Record review of Resident 1's Quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 4/9/24 revealed an admission date of 1/6/24 with diagnoses that included progressive neurological conditions, Alzheimer's disease, anxiety disorder and depression. The MDS identified that Resident 1 had a BIMS (Brief Interview for Mental Status, a brief screener that aides in detecting cognitive impairment) score of 1 which indicated severe cognitive impairment. The MDS identified that Resident 1 required supervision with eating, had no impairment in range of motion of the upper extremities, exhibited no behaviors and had no problems with skin. Record review of an Incident Note for Resident 1 dated 7/18/2024 revealed the following: Note Text: Resident was in the dining room just before lunch and had reached for [gender] coffee and [gender] spilled cup in [gender] lap. Resident was wearing a Clothing protector and it covered [gender] trunk, chest, abdomen and peri area. Coffee soaked to [gender] pant legs and pull-up. One CNA (Certified Nursing Assistant) informed that [gender] held a table cloth for privacy and the other CNA removed [gender] Coffee soaked pants and pull-up, and was brought back to this nurse. Resident was taken to [gender] room and placed in bed, where ice waster soaked wash cloths placed on [gender] inner thighs that were approximately 5 centimeter [cm] x 5 cm rectangle area that is deeper pink. These wash cloths were changed frequently q [every] 10 to 15 minutes to remove any heat on the skin, resident tolerated well and was cooperative. Area on inner left thigh faded and is currently skin tone, area on right side slightly pink sporadic with a small raised area that is not fluid filled at this time, but appears to be a possible blister that may or may nor reabsorb. A TORB to [provider] to put Silver Sulfadiazine cream 1% [ a topical cream used to treat and prevent infections in people with severe burns] on effected areas in inner thighs once per shift and PRN [as needed], until healed. Daughter called and verbalized understanding. Record review of Resident 1's Physician Orders dated 7/18/22 revealed an order for Silver Sulfadiazine cream 1% apply topically to inner thighs 3 times daily and as needed. Record review of Resident 1's Skin Evaluation dated 7/22/24 revealed a second ( burn can be red, have developed a fluid filled blister and is painful) or third degree (destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons) burn to the right inner thigh that measured 4.0 cm in length, 1.25 cm in width and 0.0 cm in depth. The area had no exudate [fluids] and no odor. Record review of Resident 1's Comprehensive Care Plan (CCP, a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated revised on 6/25/24 revealed that Resident 1 had impaired cognitive function related to Dementia. An intervention was initiated on 7/22/24 that read: provide resident with a lidded cup at all meals. The CCP in Resident 1's Electronic Medical Record [EMR] did not include information related to burn risk or having had an actual burn on 7/18/22. Record reviewed of Staff Communication provided on Friday 7/18/24 in the Nursing Communication Book revealed the following: [Resident 1] had a hot liquid spill and staff needed to ensure that [Resident 1] is getting a lidded no spill cup with [gender] meals and when offering [gender] coffee or hot drinks. The communication was signed by the DON on 7/18/24. Record review of Resident 1's EMR revealed that no hot liquid risk assessments had been completed prior to 7/22/24 related to the risk for hot liquid burns. A Hot Liquid Risk Screen was completed by facility staff on 7/22/24 for Resident 1 and identifed that Resident 1 had had a burn from a hot liquid spill on 7/18/24. The risk screen dated 7/22/24 revealed that Resident 1 scored a 9 on the risk screen. A score between 6 -9 indicated moderate risk. This score indicated that Resident 1 was at moderate risk for burns from hot liquids. Observation on 7/22/24 at 7:00 AM revealed 2 pots of coffee brewed in the facility kitchen. Dietary Aide [DA] A poured a cup of coffee into a cup and took the temperature of the coffee with the facility thermometer. The coffee temperature registered 166 degrees Fahrenheit. DA A wrote down the temperature of the coffee on a Coffee Temperature Log Sheet dated July 2024. DA A took the lids off of the coffee pots to let the coffee cool. Observation on 7/22/24 at 7:40 AM revealed DA A and DA B poured several cups of coffee for residents, including Resident 1. DA A and B let the coffee sit on the counter in the preparation area for approximately 3 minutes, did not obtain the temperature of the coffee and served the coffee to the residents. Observation on 7/22/24 at 11:30 AM revealed DA A poured coffee into a cup and took the temperature of the coffee with the facility thermometer. The coffee temperature registered 172 degrees Fahrenheit. DA A wrote down the temperature of the coffee on a Coffee Temperature Log Sheet dated July 2024. DA A took the lids off of the coffee pots to let the coffee cool. Observation on 7/22/24 between 10:30 and 10:45 AM with LPN D, the Director of Nursing [DON] and Resident 1's son revealed the following: Observed Resident 1 lying in bed with a brief in place. The inner thighs were exposed for the observation. Observation of the residents left inner thigh showed that areas of burn were resolved and skin was clear with a single pinpoint area of redness present. Observation of the right inner thigh revealed several reddened areas with a half fluid filled blister present in the center of the reddened area. LPN D described the inner right thigh blister area as a half fluid filled blister, approximately 1.5 cm, that had partially reabsorbed with portions that were granulated in. No open areas were observed. The resident exhibited no pain and, when asked, the resident stated no pain. LPN D performed hand hygiene for 20 seconds, donned clean gloves and applied Silver Sulfadiazine cream 1% to the reddened surfaces of the inner right thigh area, to the blister area on the inner right thigh and to the pin point red area on the left inner thigh. LPN D removed the soiled gloves and performed hand hygiene. Interview on 7/22/24 at 7:05 AM with DA A revealed that the temperature of the coffee is taken before each meal and logged on the check sheet. We wait a bit to serve it to the residents to let it cool a bit. We also only pour the cup half full, give 2 residents a cup with a lid and can add ice to it if needed to cool it down. The only residents that I know of that need lidded cups are (Resident 1 and Resident 2). I don't know anything about who is at risk for burns except just that I was told that [Resident 1] needed a lidded cup after [Resident 1] got a burn from coffee so now we give [gender] a lidded cup for [gender] coffee. Interview on 7/22/24 at 7:15 AM with Licensed Practical Nurse [LPN] D revealed that they did not do a formal hot liquid risk assessments on the residents to LPN D's knowledge. The kitchen tests the temperature of the coffee before each meal. LPN D stated there were 2 residents [Residents 1 and 2] that used cups with lids due to hot coffee spills that resulted in burns. The dietary staff only fill the coffee cups half full, let it sit awhile before giving to them and add ice if they feel it is too hot. They also ask the residents if it is too hot. If we see someone looks shaky, we will get them a cup with a lid and tell the Dietary Manager or the DON. LPN D confirmed that Resident 1 had gotten a burn from a hot coffee spill on 7/18/24. Interview on 7/22/24 at 10:48 AM with LPN D confirmed that Resident 1's burn treatment was ordered 7/18/24 and provided three times per day and as needed until healed. LPN D stated that the areas were healing and appeared improved. Interview with the facility Administrator on 7/22/24 at 11:55 AM confirmed the Policy entitled Hot Liquid Safety, with an effective date of June 2024, was done after a resident had received a burn on 4/30/24. The Administrator confirmed that the policy was revised July 2024 after Resident 1 had gotten a hot liquid burn on 7/18/24. The Administrator confirmed that the residents had not been assessed for their ability to handle containers and consume hot liquid prior to 7/22/24 and that no Hot Liquid Risk Screen had been completed until 7/22/24 for Resident 1. Record review of staff education on Hot Liquid Safety provided on 5/16/24 for Nurse's and all Nurse Aides on 5/30/24 included the following interventions: - Dietary will be checking the temperature of hot liquids started May 1st since had a burn 4/30/24. - Be Observant! If you see a resident who may look like they are having difficulty with their coffee cup I.E. hands shaking, etc, get a different cup from dietary as dietary is ordering special cups to prevent spills. - If you have a concern with a resident and their ability to use a cup, notify Dietary or management (if you are a nurse), or the nurse ( for MA/NA) who will relay information to the appropriate department. - Any incidents with liquid require an incident report and notification of appropriate departments, i.e. administration, PCP and POA. Interview on 7/22/24 at 9:59 AM with the Regional Nurse Consultant [RNC] confirmed that no hot liquid risk assessments had been completed on the residents in the facility prior to 7/22/24. The RNC confirmed that the education provided to staff on 5/16/24 and 5/30/24 had not been specific and left the decision of who was at risk for hot liquid burns up to the dietary aides, nurse aides and nurses to decide. The RNC confirmed that no hot liquid assessments had been completed on any residents after a burn had occurred for a resident on 4/30/24. The RNC confirmed that the MDS Coordinator was doing a hot liquids risk assessment on all residents in the facility on 7/22/24 to get a baseline for each resident. The RNC stated that the facility had implemented a quality assurance plan of correction on 7/19/24 that included hot liquid assessments on admission, quarterly and as needed. Record review of a list of residents that were evaluated by Hot Liquid Risk Screen on 7/22/24 revealed a total of 10 residents identified at risk for hot liquid burns. Five residents were identified at moderate risk and needed lidded cups. Four residents were identifed at high risk but did not consume any hot liquids. One resident was identified as high risk but took nothing by mouth [NPO].