Complaint # NJ 180316 Based on interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to provide adequate supervision for a cognitively impaired resident with a known history of exit-seeking behaviors which resulted in the resident eloping on 11/20/2024. The deficient practice was identified for 1 of 2 residents reviewed for elopement (Resident #12). Resident #12, who was cognitively impaired with a known history of exit-seeking, eloped from the facility on 11/20/2024. The staff reported last seeing Resident #12 in their room at 6:15 AM on 11/20/2024. The resident wore a wanderguard (a personal alarm that triggers at exits to alert staff) to their right ankle that the physician ordered to be checked for placement and function every shift, and was last checked during the night shift on 11/19/2024. On 11/20/2024 at 6:39 AM, the local police department called the facility to report that Resident #12 was found off the facility's premises at an adjacent assisted living facility. Resident #12 was returned to the facility by the Emergency Medical Technicians (EMT) at approximately 7:15 AM. At that time, a full-body assessment of Resident #12 was completed and no injuries were noted. The facility's failure to provide adequate supervision to a cognitively impaired resident who was at risk for elopement and eloped posed a likelihood of serious harm, injury, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 11/20/2025 at 6:15 AM, when Resident #12 was last seen. The facility's Administration was notified of the IJ on 3/20/2025 at 3:15 PM. The facility submitted an acceptable Removal Plan (RP) on 3/21/2025. The survey team verified the implementation of the RP during the continuation of the on-site survey on 3/21/2025. The evidence is as follows: A review of the facility's policy titled, Elopement of Resident revised on 5/1/2024, revealed under Policy that; Resident will be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. A review of the electronic Medical Record (EMR) on 3/19/2025 at 11:55 AM, revealed the following: According to the admission Record face sheet (an admission summary), Resident #12 was admitted with diagnoses including but not limited to; senile degeneration of brain (a group of conditions that cause a progressive decline in cognitive abilities, such as memory, thinking, and reasoning) and unspecified dementia, severe, with agitation. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 10/15/2024, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated that Resident #12's cognition was severely impaired. A further review of the MDS indicated the resident ambulated independently with no assistive devices and used a wander/elopement alarm daily. A review of Resident #12's individualized comprehensive care plan (ICCP) initiated on 7/15/2024, identified the resident as at risk for elopement and was revised on 11/20/2024, for an actual elopement. Interventions included; the resident will not attempt to leave the facility without an escort initiated on 7/15/2024, utilize and monitor security bracelet per protocol initiated on 7/15/2024, and utilize diversion technique as appropriate to redirect the resident if he/she nears exits or doorways. A review of the Order Summary Report revealed a physician's order dated 09/11/2024, for a wanderguard device placed on the resident's right ankle due to poor safety awareness A21350907 (identification number) and expiration: 7/2027 (update order with new date when bracelet is changed); every shift to check for placement. A review of the Treatment Administration Record (TAR) dated 11/01/2024-11/30/2024 revealed the physician's order for the wanderguard was signed as having been checked for placement and function on 11/19/2024, during the 11:00 PM and 7:00 AM shift. A review of an Elopement Evaluation dated 10/14/2024, revealed that a wanderguard device was needed and applied on 7/27/2024, to the right ankle. A review of the Progress Notes (PN) dated 07/13/2024 at 4:31 PM, revealed that the resident was exit seeking due to looking for their spouse. The PN revealed that on the same date at 5:36 AM, the resident was observed walking around the unit asking for an exit and at one time set off the door alarm. A PN dated 8/16/2024 revealed that at 4:11 PM, the Psychiatric Nurse Practitioner documented that the resident was exit-seeking and was redirected at that time. A PN dated 11/4/2024, revealed that the resident had worsening agitation, a failed gradual dose reduction (tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) of an antipsychotic drug, escalating agitation, and was not easily redirected. A review of the facility's Investigation and Summary dated 11/20/2024, revealed the following under the Resident's Pertinent Medical Information: the resident was ambulatory without an assistive device. The resident had a wanderguard device on their ankle for poor safety awareness. Under the Description of the event on 11/20/2024, included the following: The facility staff last reported seeing Resident #12 in their room at 6:15 AM. At 6:39 AM, the local police department received a call that an individual had been found by staff from an adjacent assisted living facility. At approximately 6:50 AM, the local police department called the facility to notify that Resident #12 had been found safe. Resident #12 was returned to the facility by the EMTs at approximately 7:15 AM. At that time, according to the Investigation and Summary, Resident #12 was wearing a wanderguard when they exited the facility. The wandergaurd was checked upon return and was still functioning properly. Resident #12 was assessed and no injuries were determined. At that time, staff checked all residents in the facility to be sure they were accounted for and closely monitored Resident #12 while the facility waited for the Electronic Service Company for the wandergaurd system to arrive. The summary revealed that an audit was completed of all exit doors to ensure they properly closed and latched. It was determined that the wanderguard system on the egress door from the secured unit into the main dining room was functioning intermittently. Staff were assigned to monitor the door until the doors could be assessed by the Electronic Service Company. The company was contacted immediately and came to assess the functionality of the doors. Repairs were made to ensure the doors were safely operating. A review of the facility's Investigation and Summary under Investigation Findings revealed that it was inconclusive how Resident #12 exited the facility. A review of the Investigation and Summary under Conclusion and Resolution revealed that the care plan was reviewed and updated with additional interventions. The medical doctor and family were notified. The Department of Health and Long Term Care Ombudsman were notified. The Electronic Service Company conducted an assessment of all wanderguard doors and made repairs if needed to ensure all doors functioned properly. Daily maintenance checks of all exit doors with a wanderguard to be sure they functioned properly. Nursing staff checked the wanderguard bracelets daily to ensure function. A review of an invoice dated 11/20/2024, from the Electronic Service Company revealed that a wanderguard inspection of all doors was done today due to an elopement. The wanderguard at the door was not working. Door #24 which led to the service corridor was determined to be defective. The invoice revealed Door #28, which led to the parking lot and could be accessed from Door #24, was determined by the company to not be equipped for wander control of wanderguards. The Electronic Service Company installed the wanderguard control system at that time. The invoice revealed that Door #18, which was the entry/exit of the B-Unit, was determined to have a faulty magnetic lock. A review of a typed letter from the Electronic Service Company dated 11/22/2024, revealed: Double doors service corridor 135DE panel found to be faulty. Replaced panel and tested good. Set loiter for 15 seconds. The loading dock was just access control, upgraded from 500 into 135DE as requested. Tested good. Set loiter for 15 seconds. B-Unit double doors entry/exit replaced faulty magnetic lock and tested good. A review of a handwritten statement signed by the Certified Nurse Aide (CNA #1) on duty 11/19/2024, revealed the following: Resident was not see leaving but was noticed [the resident] was missing around 6:45 AM check on [the resident] at 6:15 AM, resident was sitting in room in bed. I was notified by nurse at 6:40 AM. A review of a handwritten statement signed by the Licensed Practical Nurse (LPN #1) on duty on 11/19/2024, revealed the following: I was told by the nurse that police called A wing reporting that they had [Resident #12] in their custody. The last time I saw the above resident was around 5:45 AM while [the resident] was standing by the door to [the resident's] room as I was passing my [medications]. That was the last time I saw [the resident] because I had to go to another hallway to give my [medications]. A review of a handwritten statement signed by CNA #2 on duty on 11/19/2024, revealed the following: The nurse told me that the resident escaped and is with the police. The last time I was with the resident was around a little at 6 AM. Because after my rounds I went on a break to the smoking station. A review of a handwritten statement signed by LPN #2 on duty 11/19/2024, revealed the following: At 645 [AM]-A-wing nurse reported police called to say they have [Resident #12]. Went into room to see [the resident's] bed empty. I last saw [Resident #12] sitting in [their] chair at approximately 5:30 AM in [the resident's] room. I was down the hall with another resident for [approximately] 20 minutes. I did not hear a door alarm. During an interview with the surveyor on 3/20/2025 at 11:09 AM, the Licensed Nursing Home Administrator (LNHA) stated that the egress door (Door #18) from the secure unit into the dining room worked intermittently. The LNHA continued that the door used to be activated by a push button but was now an electronic numeric pad, and the system shut down upon the approach of a wanderguard device. The LHNA stated that the door into the service area (Door #24) that went towards the kitchen was worked on by the Electronic Service Company. The LNHA stated that the camera located over the B-Wing nurses station did not cover Door #18 and that the cameras worked intermittently as well. The LNHA stated there was no camera footage that captured of Resident #12's elopement. During an interview with the surveyor on 3/20/2025 at 12:06 PM, the Maintenance Director (MD) and the LNHA revealed the following information: The MD had been employed at the facility since 2019 and stated that every Sunday, he checked the doors on A-Wing and B-Wing with a wanderguard bracelet at each keypad to ensure it locked and beeped. The MD stated that meant that it was locking and not allowing the doors to open. The MD stated he then put the tag away went back to the lock and tested for a fifteen second push, for emergencies. Once the lock was released, he closed the door, cleared the alarm, and marked that it was checked. The MD stated that every single door that had a keypad was included in the checks. When asked by the surveyor if he was aware that Door #18 functioned intermittently prior to the elopement, the MD replied, Yes, I did. When asked by the surveyor if he was aware that Door #24 was defective prior to the elopement, the MD replied, That thing never worked since I've worked here. The only thing I can say is probably a mistake of human. An acceptable RP was received on 3/21/2025 at 10:48 AM, which indicated the action the facility took to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including; Resident #12's skin was assessed without injury, their wanderguard was checked for placement and functioning without identified issues, Resident #12 was seen by psychiatric services within twenty-four hours without medication modifications and their plan of care was updated after Interdisciplinary Team review, the exit door on the unit was monitored by rotating staff pending vendor arrival, the MD conducted a house wide audit of all doors to ensure the wandergaurd system was functioning, the Director of Nursing (DON)/designee performed a house wide audit of all residents at risk for elopement to ensure appropriate monitoring was in place, the DON and Staff Educator completed education and initiated competencies on facility's Elopement Policy. The survey team verified the implementation of the RP during the continuation of the on-site survey on 3/21/2025. NJAC 8:39-27.1(a)