**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, Emergency Medical Service (EMS) personnel interview, and staff interview the facility failed to provide supervision to prevent a resident with severe cognitive impairment from exiting the facility unsupervised and without staff's knowledge. On 1/22/24 Resident #83 was found by EMS personnel approximately 1.9 miles from the facility seated on the ground on a sidewalk outside at 3:05 AM with icicles hanging from his nose and beard. He was treated for hypothermia by EMS and was taken to the hospital. This was for 1 of 3 residents reviewed for accidents. Immediate Jeopardy began on 1/22/24 when Resident #83 exited the facility unsupervised and without staff's knowledge. Immediate Jeopardy was removed on 1/23/24 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Findings included: Resident #83 was admitted to the facility on [DATE] with diagnoses that included aphasia (loss of the ability to understand or express speech) and hemiplegia (paralysis of partial or total bodily function) and hemiparesis (one sided weakness) following cerebrovascular disease (a group of conditions affecting blood flow and blood vessels to the brain) affecting right dominant side. Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was assessed as severely cognitively impairment with no wandering or behaviors. He was assessed as having unclear speech with the inability to understand or be understood. He had no functional impairment with range of motion. Resident #83 required partial/moderate assistance in transitioning from sitting to standing and chair to bed, and wheeling himself in a manual wheelchair 150 feet. Review of a wandering assessment dated [DATE] revealed Resident #83 was at risk for wandering. The assessment revealed he was ambulatory with a diagnosis of cognitive impairment which led to a score of 9 indicating he was at risk for wandering. The scoring scale for the wandering assessment indicated the following: 0-8 was low risk, 9-10 was at risk, and 11 and up was high risk. Resident #83's active care plan as of 1/21/24 revealed there was no care plan in place related to wandering. An incident investigation completed by the Administrator dated 1/22/24 revealed Nurse #2 received a call on 1/22/24 at 3:45 AM from a local emergency department asking if Resident #83 was a patient of the facility as he was in the emergency department. He was brought to them via the police. Nurse #3 stated she last saw Resident #83 at 12:30 AM on 1/22/24. Nurse Aide #1 (NA) #1 stated she last saw Resident #83 between 1:00 AM and 2:40 AM. During a phone interview with Nurse #2 on 1/26/24 at 8:25 PM she stated she was notified by the local hospital on 1/22/24 at 3:45 AM Resident #83 was in the emergency room. She reported she notified his assigned nurse, and she had no other knowledge of the incident. A phone interview was conducted with Nurse #3 on 1/26/24 at 12:59 PM who stated on 1/22/24 at 3:45 AM she was notified by Nurse #2 Resident #83 was found by the police and transported by EMS staff to a local hospital. She stated she last saw Resident #83 on 1/22/24 at approximately 12:30 AM when she checked his BiPap machine (a machine that supplies pressurized air to airways). She reported he was lying in bed, and she was unsure if he was asleep. Nurse #3 reported she was unable to recall what he was wearing. She stated usually when she saw Resident #83, he was in his bed. She indicated she wasn't familiar with his ability to ambulate. During an interview with NA #1 on 1/25/24 at 4:03 PM she indicated she was Resident #83's assigned NA on 1/22/24 during the 3rd shift. She reported Resident #83 ate his dinner late on 1/22/24 and she collected his tray at approximately 11:30 PM. Initially she was unable to recall when she last saw Resident #83 so she walked through the events of that night/early morning. She stated around 2:30 AM they finished moving another resident to a different room and she knew she last saw Resident #83 before beginning that move. She estimated the last time she saw Resident #83 was at approximately 1:30 AM. NA #1 stated she was unsure about the exact time because she didn't wear a watch. She indicated the last time she saw Resident #83 he was lying in bed and was awake. She did not recall what he was wearing. She stated she was very surprised he left the building because he moved very slowly. NA #1 stated Resident #83 frequently would take a geriatric chair (a padded chair with a wheeled base) and push it slowly down the hall. EMS records indicated a call was received from law enforcement at 2:59 AM on 1/22/24 and they were dispatched at 3:00 AM. Resident #83 was found outside approximately 1.9 miles away from the facility at 3:05 am. He was sitting on the ground with icicles hanging from his nose and beard. He indicated he was attempting to walk from home to the hospital because he felt sick. Resident #83 was cold to the touch and his temperature when taken read low. The main impression listed on the EMS report was hypothermia. He was treated with active rewarming and a space blanket was applied. He was transported to the local hospital. A phone interview was conducted with EMS Staff on 1/29/24 at 4:07 PM who stated Resident #83 was found on the side of the road on a sidewalk in front of a house. He reported Resident #83 was very close to an interstate highway. EMS Staff stated it was very cold and he believed the wind chill was in the teens or single digits. He stated there was no precipitation at that time. He stated Resident #83 had icicles on his nose and beard. EMS Staff stated Resident #83's speech was very garbled, but he stated he had been outside for 4 hours. He stated treatment for hypothermia was provided on the scene which consisted of active warming, heat packs in the arm and groin and a tinfoil blanket with several blankets on top. He stated the 911 call came from the police. Review of hospital records for Resident #83 for 1/22/24 revealed he was seen with a chief complaint of cold exposure. The record indicated he walked out of his facility and was found near an interstate highway by police and EMS. He was wearing a t-shirt and it was currently 19 degrees Fahrenheit out. He was cold to the touch but his core temperature was 99.6. degrees Fahrenheit. He was noted to be alert to self and was aware he was at the local hospital. He was unaware of the situation and was noted to be confused. His family member informed the hospital he resided at the facility and stated he must have wandered off. His facility was called and staff member was unaware patient was missing from the facility. Family indicated he was confused at baseline and had a hard time speaking since his most recent CVA (cerebrovascular accident) a few months ago. Diagnostic testing was completed and he was discharged back to the facility later that morning. Review of a nursing progress note revealed Resident #83 returned to the facility at approximately 10:15 AM on 1/22/2. Observation on 1/25/24 at 6:35 PM of the intersection where Resident #83 was found by EMS revealed a four-lane road with a turning lane. The street had a posted speed limit of 35 miles per hour. There were sidewalks on each side of the street. Mapquest.com indicated the location Resident #1 was found was 1.9 miles from the facility and approximately 0.2 miles to the interstate highway. The estimated walking time from the facility to the location he was found was 42 minutes. On 1/26/24 at 11:41 AM an observation was conducted with the facility Rehabilitation Director who measured the distance from Resident #83's room to the front door. The measurement was 128 feet. Observation on 1/26/24 at 1:52 PM revealed the front door of the facility faced a four-lane road with a speed limit of 40 miles per hour. The recorded temperature on 1/22/24 at 2:51 AM in the area the facility was located was 22 degrees Fahrenheit (www.wunderground.com). Attempts to interview Resident #83 were not successful. An interview was conducted on 1/25/24 at 2:50 PM with NA #2 who reported she was familiar with Resident #83's care. She stated he never indicated he wanted to leave the facility and she never observed him leaving the facility. NA #2 stated Resident #83 was intelligent. She added the way to leave the building was to push the black key fob and then push the silver button. NA #2 stated there was someone at the reception desk until midnight. She stated she felt Resident #83 may have watched staff open the door and figured out how to open the door. During an interview with Receptionist #1 on 1/25/24 at 3:02 PM she stated the front desk was staffed until midnight and the front door was always locked. For someone to leave, either the receptionist electronically unlocked the door or there was a key fob hanging above the silver button you pushed to unlock the door. There was a camera located at the end of the lobby area that viewed the front door. An interview was conducted with the Administrator on 1/25/24 at 4:30 PM who stated the camera located in the lobby area was not operational. Observation and an interview were conducted with the Administrator on 1/26/24 at 11:40 AM. The front entrance had 2 sets of double doors. The Administrator indicated the interior door was opened using a black key fob that was observed hanging on the door. He further revealed after the black key fob was used the handicap access button could be used open to the interior door. The Administrator was observed to push the black key fob, push the handicap access button and the interior double door opened. The exterior door did not require a key fob to open. It was operated by using the handicap access button. The Administrator was notified of Immediate Jeopardy on 1/25/24 at 5:35 PM. The facility provided the following immediate jeopardy removal plan with a removal date of 1/23/24. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to prevent a Resident from exiting the facility unsupervised. Per report of EMS resident was noted laying on the side of the road. The facility staff reported last seeing the resident at approximately 1:30-2:00 a.m.; the resident was lying in bed. At approximately 3:30 a.m. the Licensed Nurse was made aware by the Charge Nurse in the local emergency department that the resident was being evaluated there, but no treatment was indicated, and transportation would be arranged to transfer the resident back to the facility. When the resident left the facility, he was not appropriately dressed for the cold weather conditions. He was wearing shoes, jogging pants and a short-sleeve shirt. Resident #83 had been brought to the Emergency Department by Emergency Medical Services who treated the resident for hypothermia in route to the hospital. Resident #83 was evaluated at the local hospital with no treatment indicated. The DON, Administrator, and Medical Provider were immediately notified. Resident #83's wife was notified. Resident #83 was admitted to the facility for long-term care on 11/18/23 with diagnoses including cerebral vascular accident. Resident #83 was assessed upon admission for elopement. Resident #83 was not High Risk on Wander Assessment completed on 11/18/23 and 1/18/24. Resident #83 is alert and oriented to person and place with a Brief Interview Mental Status Score of 0 on 1/11/24 Minimum Data Set. On 1/22/24 at approximately 4:00 a.m. the Administrator (NHA) conducted an Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee meeting via telephone conference with Director of Nursing (DON), and Regional [NAME] President of Operations to discuss incident, review facility elopement policy and to initiate an immediate performance improvement plan based on root cause analysis. Root cause analysis determined that the facility failed to prevent a resident from exiting the facility by failure to ensure a staff member noted Resident #83 exited the facility. The facility doors were all checked and were secured and functioning. The Root Cause analysis determined that the resident was able to exit the front door by pressing the exit button and key fob release. To prevent recurrence, the QAPI Committee initiated a Front Door Protocol for after hours. The Receptionists work until 11:00 p.m. or 12:00 a.m. seven days a week. The Front Door Protocol includes the key fobs will be secured after hours by the Receptionist. One key fob will be locked in the cabinet behind the receptionist desk. The other key fob will be stored behind the receptionist desk in the plastic storage bin which is not accessible to residents. Beginning 1/22/23 all staff will be educated on the Front Door Protocol by the NHA, DON, Assistant DON, Business Office Manager, or their respective Department Manager prior to the start of their next shift. On 1/22/24 Resident #83 returned to facility at approximately 10:15 a.m. and was assessed by the licensed nurse without injury or pain and vital signs at baseline. An updated Wandering Risk Assessment was completed by the Licensed Nurse and scored High risk for elopement based on exiting the facility on 1/22/24. A wander guard placed to his right ankle and continuous 1:1 staff supervision initiated. His care plan, care card, and physician orders were updated accordingly by the Licensed Nurse to reflect the resident is now High Risk for elopement. The Elopement Binder at the nurses' stations and Receptionist Desk was updated. An Elopement Risk Binder is a binder which contains pertinent information about residents who are at High Risk for Elopement. This includes resident description and picture of the resident. A Post Trauma Assessment was initiated and completed by the Licensed Nurse on 1/22/24 and 1/24/24 with no changes from baseline completed on 11/18/23. Effective 1/22/24 Resident #83 will remain on 1:1 supervision until no longer indicated as determined by the Interdisciplinary team, Medical Director, and reviewed and approved by the Quality Assurance Performance Improvement (QAPI) Committee. The Interdisciplinary Team includes the DON, Assistant DON, Social Worker, Activities Director, Unit Managers, and NHA. QAPI Committee includes the Medical Director, DON, Assistant DON, Social Worker, Activities Director, NHA, Business Office Manager, Maintenance Director, Rehab Coordinator, and Unit Managers. Residents who exhibit exit-seeking behaviors, residents with cognitive impairment, and residents who are assessed as High Risk for Elopement are at risk of exiting the facility without supervision. On 1/22/24 at approximately 3:30 a.m., the facility initiated a 100% census verification by the Licensed Nurses and all residents accounted for and safe. On 1/22/24 all facility doors and windows and wander guard system doors verified as secure and properly functioning by the Maintenance Director and NHA. No concerns identified. On 1/22/24, the licensed nurses completed an elopement audit by updating Wandering Risk Assessments for all current facility residents to identify those at risk for elopement and to ensure an appropriate care plan and care card in place and current wander guard orders with monitoring for proper placement and function. Elopement risk binders were verified for accuracy, completeness and placement at nurse stations and reception desk with copy of resident profile, photo, and care plan by the Director of Nursing (DON). Residents were also reviewed for any behavior of removing and/or attempting to remove wanderguard device. No additional residents were identified as a current risk. On 1/22/24 the Administrator, Admissions Coordinator, Regional Marketing Director, and Social Services Director re-educated all current cognitively intact residents, with a BIMS of nine or greater, who are not at high risk of elopement to please notify the nurse if they would like to exit the facility. Each resident who was educated validated their understanding of the education provided. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Effective 1/22/24 a Front Door Protocol was initiated for after hours. The Receptionists work until 11:00 p.m. or 12:00 a.m. seven days a week. The Front Door Protocol includes the key fobs will be secured after hours by the Receptionist. One key fob will be locked in the cabinet behind the receptionist desk. The other key fob will be stored behind the receptionist desk in the plastic storage bin. On 1/22/24 the Administrator, Director of Nursing, Assistant Director of Nursing, and Unit Managers educated nursing staff regarding Assessment Wander Protocol, visually seeing each resident every two hours and the requirement for cognitively intact residents to sign out prior to leaving the facility, for resident safety. The Director of Nursing and Assistant Director of Nursing will ensure no staff will be allowed to work, including any newly hired staff and agency staff, without first receiving this education. Effective 1/22/24 a keypad lock was ordered to be placed at the front door as an additional measure to prevent residents from exiting the facility unsupervised. A code will be required to be entered to exit the facility. This additional measure will be implemented in conjunction with the key fob securing the front door. On 1/22/24 the Administrator and DON conducted an elopement drill with current facility staff and initiated elopement education with all current facility and agency staff. Education included 1) review of the Elopement policy, 2) Special emphasis on providing routine care rounds every two hours and as needed and visually observing each resident 3) Special emphasis on Front Door Protocol initiated with education provided to all staff 4) IDT including the DON, Assistant DON, Social Worker, Activities Director, Unit Managers, were educated by the NHA to review of residents at-risk for elopement during Monday - Friday morning meeting for changes of condition and behaviors and/or need for revision of care plan with communication to nursing staff with any changes. The NHA was educated on the preceding information by the Regional [NAME] President of Operations on 1/22/24 in order for the NHA to educate the IDT. Facility and agency staff not receiving initial education on 1/22/24 will not be permitted to work until education is completed. The Assistant Director of Nursing will be responsible for ensuring education completion. On 1/22/24 at approximately 4:00 a.m. the Regional [NAME] President of Operations provided education to the Administrator and DON on the elopement policy and facility responsibility of maintaining an effective process to prevent residents from exiting the facility without supervision to ensure safety. 1) Completion of root cause analysis identified front door key fob was not secured allowing resident #83 to exit the facility unsupervised. 2) Front Door Protocol to be initiated to secure the front door key fob after the receptionists leave 3) keypad lock to be installed at front door requiring a code to exit the front door after the receptionist leaves 4) interventions to prevent an unsupervised exit from the facility of an at-risk resident and ongoing monitoring to include every 2 hours and as needed visual observations of each resident in the facility, 3) interventions to enhance staff awareness of residents identified at risk and ongoing monitoring and 4) maintaining an effective QAPI program whereby the Interdisciplinary Team (IDT) monitors the effectiveness of the corrective action plan of the elopement prevention program and makes changes to the plan as necessary to maintain compliance with preventing residents from unsupervised exits of the facility. Newly hired DONs will receive education during the orientation process. Alleged date of immediate jeopardy removal: 1/23/24 Onsite validation of the immediate jeopardy removal plan was completed on 1/26/24. Interviews verified the facility had implemented an afterhours front door protocol where key fobs are secured after the receptionist leaves for the evening. Interviews confirmed nursing staff were educated on visually seeing each resident every two hours and the requirement for cognitively intact residents to sign out prior to leaving the facility. Education included review of the new front door protocol. Record review revealed an elopement drill was conducted 1/22/24. Record review also revealed the administrator and Director of Nursing were educated by the Regional [NAME] President of Operations on the elopement policy and the facility responsibility of maintaining an effective process to ensure residents did not exit the facility without supervision. Observation revealed a new front door keypad with a code required for entry and exit for staff. The immediate jeopardy removal date of 1/23/24 was validated.