**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, staff, Legal Guardian, Dialysis Nurse and Nurse Practitioner interviews the facility failed to prevent Resident #49's unauthorized and unsupervised exit from the facility. Resident #49 was ruled incompetent, had a legal guardian and had verbalized the desire to leave to several staff members. This affected 1 of 3 residents (Resident #49) reviewed for supervision to prevent accidents. Resident #49 was unsupervised and eloped from the facility's fenced in patio/smoking area the night of 6/17/21. The facility failed to communicate the 6/17/21 elopement to the dialysis center and Resident #49 was left unsupervised outside the dialysis center waiting on transportation on 6/25/21. As a result, Resident #49 eloped from the dialysis center and propelled himself two businesses down on a busy two-lane road. Resident #49 was found at a store by a dialysis center staff member and was taken back to the dialysis center. Immediate jeopardy began on 6/17/21 when Resident #49 exited the facility's fenced in smoking area unsupervised. The immediate jeopardy was removed on 7/4/21 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: Review of Resident #49's court orders revealed on 02/25/21 Counseling Center received legal guardianship of Resident #49 and he was ruled incompetent by the courts. Guardianship included Resident #49 needed assistance taking prescribed medications, communicate regarding health decisions, seek medical help for serious problems, keeping a sanitary living environment, to identify and void life-threatening behaviors, recognize and avoid hazards in home, seek help in emergencies, and capacity to make decisions without undue influence from others. Resident #49 was admitted to the facility on [DATE] with diagnoses that included renal failure, bipolar disorder with mania, muscle weakness, and vision impairment due to loss of right eye. A review of the Elopement Risk Evaluation for Resident #49 dated 5/14/21 revealed Resident #49 was marked for no concerns of elopement. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 was assessed for being cognitively intact and requiring extensive assistance with one person staff for activities of daily living (ADL). The MDS further revealed Resident #49 mobilized with a wheelchair and was not coded for delusions or hallucinations. Resident #49 did not have a care plan for wandering or elopement behaviors. An interview with Resident #49 on 6/27/21 at 10:23 AM revealed a week half ago he escaped the facility and made it to the fence line while smoking unsupervised in attempt to go home to another state and a staff member spotted him and brought him back inside the facility gate. Resident #49 revealed he also escaped again during dialysis recently while waiting on transport and made it down the road and a staff member stopped him. A further interview with Resident #49 on 6/29/21 at 4:15 PM stated his plan was to panhandle from one state to another to live with friends that he has not spoken to in 20 years. Resident #49 stated he had no plans to seek medical treatment, continue dialysis, or where he would live or what he would eat during his attempt to travel. An interview with Nurse Aide (NA) #7 on 6/28/21 at 4:15 PM revealed on 6/17/21 at 11:30 PM Resident #49 was outside unsupervised smoking and another resident notified the NA that Resident #49 was outside of the fence. The NA #7 stated Resident #49 was sitting in his wheelchair outside the fence on the bank which sloped down to a wooded area. The NA further revealed she could barely see the resident due to the darkness and she ran and jumped the fence because she was scared the resident was going to flip off the bank. NA #7 stated Resident #49 plan was to travel to a store to buy cigarettes and go to another state. NA #7 stated a staff member contacted the Administrator and a note was put up at the nurse's desk instructing the staff if the resident attempted to elope to contact the administrator and the police. The NA revealed no interventions or precautions were put into place during 2nd shift on 06/17/21. NA #7 recalled seeing the posted note during her 2nd shift for only two shifts. NA #7 stated that she was not made aware Resident #49 had spoken to staff about leaving the facility on 6/17/21. NA #7 further revealed Resident #49 had discussed leaving the facility to go to another state since his admission [DATE]). An interview with Nurse #3 on 6/30/21 at 12:15 PM revealed on 6/17/21 during 2nd and 3rd shift change another resident reported to staff Resident #49 had left the facility fenced in Nurse #3 stated when she got to Resident #49, he indicated he was going to the store to buy cigarettes but was aware he had no money. He further revealed to Nurse #3 and NA #7 that he was going to the store to make money and travel to another state. Nurse #3 revealed the Administrator was contacted and a staff member posted a note at the desk if Resident #49 attempted to leave again to contact the Administrator and the police. Nurse #3 further revealed Resident #49 had never voiced leaving the facility prior to 6/17/21 and was not made aware of Resident #49 wanting to leave the day of 6/17/21. No interventions or precautions were put into place during Nurse #3's shift. Review of incident reports revealed there were no incidents documented for Resident #49 on 6/17/21. In addition, there was nothing documented in the nurses notes and an Elopement Risk Evaluation was not completed after he eloped on 6/17/21. A review of the weather conditions per Weather Channel website revealed the following data for [NAME], North Carolina. On 6/17/21 the website indicated it was partly cloudy with the low of 59 degrees Fahrenheit at 11:30 PM. An observation of the fenced in patio area was conducted on 6/28/21 at 4:55 PM and revealed residents entering and exiting the patio without having to use a code. The cement patio had covered area with one picnic table and was surrounded by a grass area. It was further observed the patio gate that Resident #49 exited out of had a metal latch and was closed with a yellow bungee cord. Outside of the gate a cement path wrapped around the left side of the building but to the right it was observed to be a small dirt path between the fence and the tree line which sloped down to a bank. An interview with the Maintenance Director on 6/29/21 at 10:40 AM revealed a request was completed by nursing staff dated 6/17/21 for a better gate mechanism. The Maintenance Director stated he was told to leave the bungee cord in place by the Administrator because it slows down residents trying to elope. An interview with Dialysis Nurse on 6/28/21 at 2:00 PM revealed Resident #49 was left unsupervised waiting on transportation at the front of the dialysis building on 6/25/21. Resident #49 left the parking lot and propelled himself down the side of a two-lane highway traveling past a restaurant and turning into a gas station that is at the intersection of a major highway. Resident #1 was spotted by a dialysis employee who revealed cars passing were having to go around the resident and the employee was able to get the resident back to the facility. The Dialysis Nurse revealed she told the facility transporter about what had happened. The Dialysis Nurse stated they had no knowledge of Resident #1 to elope from the facility, and if they have known they would have not allowed him to go outside unsupervised. The Dialysis Nurse further stated Resident #1 would no longer be allowed to sit outside to wait on transportation. An interview with the facility transporter on 06/28/21 at 1:00 PM revealed on 6/25/21 at 3:45 PM she picked up Resident #49 from the dialysis center on 6/25/21 and it was reported Resident #49 had left the facility unsupervised. The facility transporter further revealed Resident #49 made it two buildings down on a busy two-lane road. The Facility Transporter indicated Resident #49 had discussed multiple times escaping and leaving the facility and she had relayed the information to the Administrator. Review of incident reports revealed there were no incidents documented for Resident #49 on 6/25/21. In addition, there was nothing documented in the nurses notes and an Elopement Risk Evaluation was not completed after he eloped on 6/25/21. A review of the weather conditions per Weather Channel website revealed the following data for [NAME], North Carolina on 6/25/21. The website indicated it was partly cloudy and 83 degrees Fahrenheit. An interview with the legal guardian on 6/28/21 at 8:20 PM revealed on 6/18/21 the guardian was contacted by the facility Social Worker (SW) and informed Resident #49 was making threats to leave the facility, and the facility could not stop the resident. The guardian reported she was not informed he had eloped from the facility on the night of 6/17/21 and stated Resident #49 was incompetent and could not make safe decisions for himself. An interview with the Social Worker (SW) on 06/29/21 at 11:35 AM revealed on 6/17/21 the Administrator reported to the SW Resident #49 was wanting to leave the facility through the front door that morning and go to a store to panhandle money to be able to hitch hike to another state to get his money. The SW further revealed the SW had a conversation with the Legal Guardian on 6/18/21 but did not reveal the resident had eloped the night of 6/17/21. The SW indicated she told the guardian the resident was having behaviors of possible elopement stating he was going to leave the facility. The SW indicated no interventions were put in place to prevent the resident from eloping again after Resident #49 left the facility through the patio gate on 6/17/21. The Social Worker (SW) revealed she was not made aware of his elopement from the dialysis center on 6/25/21 and was never notified to contact the guardian. The SW stated no interventions were put in place to prevent the resident from eloping after leaving the dialysis center. The SW recalled conversations with the resident, and he did not understand why he had to be in the facility. A further interview with the SW on 7/1/21 at 8:15 AM revealed Resident #49 would not be able to be discharged to the community because the resident was unable to make safe decisions and was deemed incompetent. An interview with the Nurse Practitioner (NP) on 6/29/21 at 8:50 AM revealed Resident #49 was deemed incompetent before being admitted into the facility. The NP further revealed Resident #49 was incompetent, unable to make any kind of sound medical decisions, and had threatened to leave since 5/13/21. The NP further revealed she was made aware of Resident #49's first elopement on 6/18/21 but had not examined the resident. The NP revealed she was not made aware of Resident #49 leaving the dialysis center unsupervised on 6/25/21. An interview with the Director of Nursing (DON) on 6/29/21 at 9:25 AM revealed Resident #49 had stated to the Administrator on 6/17/21 that he was going to leave the facility because he was unhappy. The DON stated she did not recall if any interventions to prevent elopement were put in place for Resident #49. An interview with the Director of Nursing (DON) on 7/01/21 at 9:15 AM revealed Resident #49 was extremely delusional and had been since admission. The DON indicated she was not informed by the dialysis center or Administrator of Resident #49 leaving the dialysis center on 6/25/21 and did not recall any interventions put into place to address his elopement. The DON stated Resident #49 should not be discharged to the community because he was unable to make safe decisions for himself. An interview with the Administrator on 6/28/21 at 1:27 PM revealed on 6/17/21 during first shift Resident #49 was unhappy and continued to state he was going to leave the facility and go to another state. The Administrator revealed she had not put any interventions or precautions in place for Resident #49 at that time. She explained on 6/17/21 at 11:30 PM Resident #49 did exit out of the smoking area through the gate with plans of going to one state then to another. The Administrator stated she did not consider it an elopement because the resident was alert and had intact cognition. The Administrator further revealed if a resident with intact cognition left the facility and was alert it was not considered an elopement. The Administrator stated she had written a note and placed it at the nurses' desk for 24 hours on 6/18/21 for staff to keep an eye on Resident #49 and contact the Administrator and police if Resident #1 was to elope. The Administrator further revealed she did not discuss the resident's behaviors on 6/17/21 face to face with staff after he had discussed leaving the facility that day prior to the elopement. The Administrator stated no interventions or precautions were put in place. An interview with the Administrator on 06/29/21 at 12:15 PM revealed she was notified by the facility transporter on 6/25/21 of Resident #49 eloping from dialysis center but felt that it was the dialysis center's responsibility the resident eloped from their facility. The Administrator stated his elopement on 6/25/21 was discussed during their morning meeting on 06/28/21 and no safety interventions were put in place for Resident #49 to prevent further elopement. The Administrator revealed the facility should have made the dialysis center aware of Resident #49's behaviors of elopement but failed to do so. The Administrator further revealed she was aware Resident #49 was incompetent at admission and given the resident history of bipolar depression, and elopement, she should have sent Resident #49 to the hospital and put safety interventions in place after the first elopement on 6/17/21. The Administrator was informed of immediate jeopardy on 07/01/21 at 1:55 PM. The facility provided the following acceptable IJ removal Plan with the correction date of 7/4/21: The facility failed to supervise a cognitively impaired resident with wandering behaviors from exiting the facility and the dialysis center unsupervised. What corrective action will be accomplished for the residents found to have been affected by the deficient practice? 1) Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #49 was admitted to the facility on [DATE] with diagnosis of renal failure, bipolar disorder with mania, unspecified symptoms and signs with cognitive functions and awareness, muscle weakness, and vision impairment due to loss of right eye. Resident #49 was ruled incompetent on 2/25/2021 by the courts and was appointed a Legal Guardian with Phoenix Counseling Center at that time. On 6/17/2021, Resident #49 attempted to exit the facility front door stating that he was going back to [NAME] Virginia, facility Administrator was present. Later, 6/17/2021 at approximately 11:00 pm, Resident #49 propelled himself through a gate in the fenced in smoking area. When Resident #49 exited the gate, the resident propelled himself behind the fence where the ground is unlevel and slopes to a drop off next to a wooded area. Another resident that was in the smoking area at the time of exit notified staff and staff went and returned Resident #49 back onto the facility. Facility did not complete an elopement assessment after either incident, implement safety interventions to address elopement or notify the Physician or Guardian. Additionally, resident receives dialysis services on Monday, Wednesday, and Friday. The facility did not communicate elopement risk to the dialysis center to ensure coordination of care for safety. On 6/ 25/21, dialysis notified the Van Driver when picking up Resident #49 that Resident #49 left the premises unassisted and propelled out of the parking lot down a busy side street to a gas station. A dialysis employee noted resident at the gas station and returned him to the dialysis center. The facility Van Driver communicated this information to the facility Administrator. The facility did not ensure safety interventions were initiated post incident on 6/25/2021 and did not notify the Physician or Guardian of the incident. On 6/29/2021 Resident #49 was assessed by Physician. Physician advised periodic safety checks, placement of a wander guard related to elopement risk, and a Psychological Evaluation. Wanderguard placed on resident by Licensed Nurse on 6/29/2021 and every 15-minute safety checks initiated. Smoking Assessment was completed on 6/29/2021 and Resident #49 was made a supervised smoker and with placement of wander guard the door to the smoking area will alarm to alert staff of his proximity to the exit door. Elopement Assessment and care plan was updated by Director of Nursing on 6/29/2021 to reflect risk of elopement. All information was added to the Elopement Risk Binder and Careguide by the Administrator and Director of Nursing. Social Worker immediately contacted Community Mobile Crisis Unit for evaluation. Community mobile crisis completed an evaluation of Resident#1 on 6/29/2021 and recommends a higher level of care (i.e., secure unit). Social worker began referral process on 6/29/2021. On 6/30/2021, Social Worker, Minimum Data Set Nurse (MDS), Senior Clinical Consultant, and Regional Clinical Consultant conducted a care conference with resident #49's legal guardian. Discussions included interventions for elopement risk, wanderguard and safety checks (15-minute checks), she agrees with plan of care as stated above. On 6/30/2021, the Administrator discussed with the Dialysis Center Social Worker the plan of care for Resident #49's elopement risk which included interventions of calling facility when dialysis is completed, and Resident #49 will remain in the dialysis center until facility transportation arrives. Dialysis Social Worker confirmed understanding of the plan of care. All residents that are at risk for elopement have the potential to be affected when policies and procedures for elopements are not followed. 2) 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 6/29/2021, residents with Wanderguards were assessed to validate placement and function of the Wanderguards by Maintenance Director. Completion date of 6/29/2021. Effective 6/29/2021, elopement assessments and care plans were reviewed and validated for all current residents assessed at risk for elopement by the Director of Nursing and MDS Nurse. Elopement risk binders were reviewed and updated as needed by the Administrator. Completion date of 6/29/2021. Effective 7/1/2021, Licensed Nurses were re-educated by the Administrator and Director of Nursing on Elopement assessments and completion. They are completed on admission, then quarterly and/or as needed by the Licensed Nurse. Any newly identified residents noted at risk will be communicated by the licensed nurse during shift huddle at the change of each shift. Effective 7/1/2021, the Interdisciplinary Team (IDT) to include but not limited to Administrator, Director of Nursing, Charge Nurse, Activities Director, Social Worker, and Dietary Manager was re-educated by the Regional Clinical Consultant and Senior Clinical Consultant on Elopement Policy to include ensuring residents who are assessed at risk for elopement are supervised by facility staff and signs of elopement risk are recognized which included: resident packing belongings, resident stays near or searching for exit doors, and/or resident verbalizes/comments of wanting to go home. Additionally, they will be educated on their role in developing plans/interventions in response to any elopement risk. This should include a written careplan with elopement risk interventions formulated in conjunction with Physician/ Responsible Party (RP) and communicated with staff. Effective 7/1/2021 - Administrator, Director of Nursing, and/or Regional Clinical Consultant initiated education with all staff in all departments including contracted employees on the facility elopement policy including ensuring residents who are assessed at risk for elopement are supervised by facility staff. Facility ensures that residents that exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. Facility will establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including assessment and identification of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Education also to include signs of elopement risk: resident begins packing belongings, resident stays near or searching for exit doors, and/or resident verbalizes/comments of wanting to go home. When the above behaviors are noted, the nurse must be notified immediately and the charge nurse. Notification to Physician/RP/Administrator and DON should occur immediately if resident displays these behaviors. Documentation of the behaviors should be documented in the Electronic Health Record as well as recorded on the 24-hour shift report. An elopement assessment should be completed by the Licensed Nurse immediately following these behaviors. Elopement assessment will be reviewed, and appropriate intervention applied as needed. Interventions for elopement attempt: Redirect, diversional activities and notify Physician/RP and DON for further interventions. Residents identified at risk for elopement will be added to the Elopement Risk Binder, there are 2 Elopement Risk Binders in the facility (reception desk, nursing station). All staff re-educated on the location of the Elopement Binders. Each book contains current wander guard resident list and individual identification forms with pictures of these residents. Each hall nurse is responsible for checking placement of the wander guard each shift and ensuring it is documented in the medical record. Maintenance, Licensed Nurse or/designee will check function of all residents with wanderguards daily. Maintenance or designee will continue routine daily door and alarm checks to ensure alarms are functioning properly (ie sounds when activated). Additionally, Director of Nursing, Social Worker, Admissions Coordinator, Business Office Manager, Maintenance Director, Dietary Manager, Therapy Director and Licensed Nurses educated on the process of reviewing Resident Profile in the Electronic Health Record to determine who has a legal guardian due to competency status, this information will be entered by the Admissions Coordinator. Resident Profile will be printed off and placed in a binder at the nurse's station for review by all staff as appropriate. The education will be communicated verbally and telephonically by the Administrator and the Director of Nursing. Written education will be available for review prior to the staff member working their assigned shift. Administrator will utilize a master employee list to track completion of education. No staff will be allowed to work until education is completed. This education will be included in orientation for New Hires. Effective 7/1/2021, the Regional Nurse Consultant will review all electronic nursing notes and 24-hour log sheets for current residents for the last 14 days to ensure there are no unaddressed elopement risk behaviors. No other residents were noted to have elopement risks which were not addressed. This review will be completed by 7/1/2021. Effective 7/1/2021, Residents at risk for elopement that need to go out of the facility for an appointment will have elopement risk communicated with the receiving entity and have an appointment escort provided (i.e., family, facility staff). Nursing staff and Van Driver will be educated by Administrator. Effective 7/1/2021 Nursing Management to include Charge Nurse and/or Director of Nursing will review 24-hour report sheets and previous day nurses notes to identify any change in condition i.e., exit seeking behavior for appropriate follow up and notification to Physician review will be completed daily. Any newly identified residents noted at risk will be communicated by the licensed nurse during shift huddle. Administrator will educate the Nursing Management team to include Charge Nurse, Licensed Nurses, Director of Nursing and Social Worker on the new process of monitoring and responsibilities of this plan by 7/1/2021. Effective 7/1/2021 the Interdisciplinary Team (Nurse Managers, Social Work) will review residents at risk for elopement weekly in the Standards of Care Meeting to ensure continued appropriate interventions are in place to include Psych referral as indicated, with collaboration from the Physician/RP. Administrator will educate the Interdisciplinary Team on the new process of monitoring and responsibilities of this plan by 7/1/2021. Effective 7/2/2021, the Administrator, Regional Nurse Consultant, Rehab Manager, and the Environmental Services Manager began conducting interviews with all staff (to include contract staff) to determine if there were any other resident exhibiting behaviors for risk for elopement (i.e. stating they are wanting or going to leave, packing belongings, wandering, or exit seeking) to ensure there are no unaddressed elopement risk behaviors. Interviews to be completed by 7/3/2021. Effective 7/1/2021, the Administrator and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. The facility alleged immediate jeopardy removal effective date 7/4/2021. The credible allegation of compliance with an immediate jeopardy removal date of 7/4/21 was validated on 7/9/21. Elopement books were observed at the nurses' station and at the front reception desk. The elopement books included pictures and descriptions of residents currently identified at risk for elopement. Staff in-services conducted from 7/2/21 through 7/8/21 were reviewed. No staff were allowed to work until they had received the in-service education. In-services included the following: review of resident elopement risk profile, elopement policy review (missing resident/patient), an elopement drill, use of a post-elopement follow-up report, and an elopement drill or post-elopement checklist. Staff were further in-serviced on how to identify a resident at new risk for elopement. A review of the signature sheets for the in-services revealed all staff were educated. Interviews with staff on 7/9/21 from 3:42 PM through 5:24 PM revealed staff indicated they were required to complete on-line education regarding wandering / elopement. Staff were able to describe location of elopement books, how to identify elopement behaviors, responses to wander-guard alarms, identity of the 4 current residents at risk for elopement, strict observation of resident smokers in outdoor patio. Nursing staff were able to verbalize timing of elopement risk assessments as being on admission, with any indication that a resident was planning to elope and following any elopement. The administrator and DON verbalized a daily check of 24-hour reports was completed at the morning meeting. The Maintenance Director provided a daily audit of magnetic door locks. The audit was reviewed with no concerns identified.