**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, review of the facility's investigation, review of witness statements, review of the facility Self-Reported Incidents (SRI), review of emergency medical services (EMS) report, review of hospital records, review of emergency room (ER) notes, review of the local weather report, and review of the facility policy, the facility failed to provide adequate supervision and implement timely interventions for exit-seeking behaviors for Resident #11, to prevent his elopement from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or death on [DATE] when Resident #11 broke the window and exited the secured building by jumping out of the second story window, approximately 15 feet from the ground level. Resident #11 suffered an open fracture to the left ankle as a result of the jump. This affected one (Resident #11) of three residents reviewed for elopements. The facility identified 18 residents who were at risk for elopement from the facility. The facility census was 74 residents. On [DATE] at 11:35 A.M., the Administrator, the Director of Nursing (DON), and Regional Clinical Officer (RCO) #800 were notified Immediate Jeopardy began on [DATE] at 1:40 P.M. when Resident #11 made threats to jump out a window, and 1:59 P.M. staff found Resident #11 on the ground outside the unit. Staff assessed Resident #11 and transferred Resident #11 to the hospital via emergency medical services. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) began interviewing staff from the unit to gather statements regarding the incident. Beginning on [DATE], the DON and ADON immediately provided education to current staff on suicidal and threatening behavior protocols and interventions, behavior management, and how to deal with challenging behaviors and the need to immediately respond to resident threats of self-harm. The resident should not be left alone or out of line of sight for their safety. If the nurse does not respond, then they should notify the DON/ADON/ Administrator. On [DATE], the DON and the ADON reviewed the suicidal ideation (SI) risk assessment/questionnaire. The DON and the ADON educated staff on the abuse and neglect policies and procedures. This education was completed for all day and night shift staff working on [DATE] by approximately 7:30 P.M. Employees working on [DATE] received the education prior to their shifts. Education for current staff was completed on [DATE]. On [DATE], the DON notified staff who were not present on [DATE] and [DATE] via online communication, they must report to the DON/ADON for education before their next scheduled shift. Starting [DATE], training will continue ongoing for all employees who have not yet received it due to paid time off (PTO), sick leave, etc., and will also be provided to all new hires. On [DATE], the ADON completed suicide risk assessments and elopement assessments for all current residents on the male secured unit, and no other residents were identified with suicidal ideations or increased/current immediate elopement risk. On [DATE], the Maintenance Director (MD) audited all second-floor windows to ensure they were secured and in place with no further issues noted. Staff secured Resident #11's room to prevent re-entry and cleared glass debris from the courtyard for safety. On [DATE], the facility Administrator opened a Self-Reported Incident (SRI) and reported the incident to the Ohio Department of Health (ODH). On [DATE], the Administrator suspended Licensed Practical Nurse (LPN) #205 who was the unit nurse at the time of the incident, pending the outcome of the investigation. LPN #205 has remained suspended and/or has not worked since the incident due to being on vacation. On [DATE] at 4:30 P.M., the Administrator and the DON notified the Medical Director and a member of the governing body (GB)/Owner of the incident on [DATE] involving Resident #11. The facility then held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting by phone with the Administrator, the DON, the Medical Director and the Facility Owner. On [DATE], the Administrator and the DON completed a root cause analysis of the incident on involving Resident #11 and determined the root cause was staff did not stay with Resident #11 when the resident verbalized an intent to leave the facility by jumping out a window and LPN #205 failed to assess Resident #11 when notified by staff. On [DATE], the ADON began questioning random staff three times weekly to verify knowledge of resident safety protocols. Results are turned into the Administrator for ongoing monitoring and compliance. The ADON will continue the monitoring three times weekly for three months. Beginning on [DATE], the management team will conduct ongoing education and continue to address any issues related to suicidal and threatening behaviors. Staff have been and will continue to be questioned by the Administrator or designee on appropriate actions to take if a resident expresses an intent to harm themselves. This will be conducted three times per week for three months, and results will be reported to the QAPI committee. On [DATE], the facility Psych Nurse Practitioner (NP) #701 and outside counseling service representatives met with all residents on the secured male unit to provide support. On [DATE] at 3:23 P.M. and on [DATE] from 10:21 A.M. to 3:20 P.M., interviews with Certified Nursing Assistants (CNA) #314, #324, and #326, LPN #205, Activity Assistant (AA) #350, and Housekeeper (HK) #500, revealed all staff were educated and verbalized knowledge of the facility's elopement policies, procedures, and guidelines for monitoring residents who have been placed on one-on-one supervision. On [DATE], RCO #800 provided re-education to the current Administrator and the acting Administrator at the time of the incident on [DATE] on the importance of a thorough investigation and the need to review the accuracy and information provided by staff. On [DATE] the Administrator notified LPN #205 that after investigation LPN #205's employment was terminated. Although the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #11 revealed an admission date of [DATE] with diagnoses including traumatic brain injury (TBI), schizoaffective disorder, and severe cognitive impairment and a discharge date of [DATE]. Review of the Preadmission Screening and Resident Review (PASARR) for Resident #11 dated [DATE] revealed the resident was recommend for admission to the facility due to diagnoses of schizoaffective disorder and bipolar disorder with an intervention of one-to-one support from staff as needed. Review of the care plan for Resident #11, updated [DATE] revealed the resident had dementia/history of TBI with memory loss with symptoms including impaired decision making, poor impulse control, poor ability to control anger, resistance to care, apathetic at time, fluctuation in mood behaviors, poor short term and long term memory, alteration in mood and/or behavior as evidenced by feeling down/depressed/hopeless, showing little interest/pleasure in doing things, history of being sexually inappropriate, history of physical aggression with peers, exit seeking behaviors, and impulsivity secondary to anoxic brain injury. The goal of the care plan was Resident #11 would not elope from the facility. Interventions included the following: observe/report any changes in mental status, secured unit placement, allow resident the opportunity to express concerns and feelings through active listening, orient resident to surrounding and ensure understanding of limitations. Resident #11 was also at high risk for elopement and had a care plan for exit seeking behaviors with a goal to not harm self or others, and an intervention to provide one on one supervision as needed. Review of Minimum Data Set (MDS) for Resident #11 dated [DATE] revealed the resident #11 had severe cognitive impairment, and was coded for delusions, hallucinations, and wandering. Resident #11 was independent with mobility and transferring, Resident #11 weighed 219 pounds and was 70 inches tall. Review of the physician order dated [DATE] revealed staff were to monitor the resident every shift for signs and symptoms of self-injury or risk-taking behavior, sleep disturbance, change in appetite and to document on behaviors observed. Review of the physician order dated [DATE] was to increase the resident's dose of Zyprexa (an antipsychotic medication to treat schizophrenia) from 10 milligrams (mg) daily to 15 mg due to increased exit seeking behaviors and other changes in behaviors. Review of a psychiatry progress note for Resident #11 dated [DATE] revealed the resident was evaluated for recent behavioral changes and medication management. Recently Resident #11 had exhibited behaviors including exit-seeking, yelling at staff, threatening to break a window, and grabbing a fire extinguisher. Resident #11's Zyprexa was increased from 10 mg to 15 mg for treatment of schizoaffective disorder. Since the medication adjustment, the resident had continued to display delusions, disorganized thinking, mood swings, and paranoia but no further aggressive behaviors were reported. Review of a progress note for Resident #11 dated [DATE] at 10:07 A.M. revealed the CNA reported Resident #11 wearing nothing but his underwear had entered another resident's room without permission. The other resident yelled for Resident #11 to get out, and the CNA intervened and told Resident #11 to leave and go back to his room. Review of an EMS report for Resident #11 dated [DATE] revealed EMS responded to a call which came in on [DATE] at 1:59 P.M. with EMS arriving at 2:08 P.M. for a male who had jumped out of a window on the second floor. Upon arrival, Resident #11 was lying on the ground with a visible open fracture to left ankle with bleeding controlled. Resident #11 was transported to local hospital. Review of hospital records for Resident #11 dated [DATE] at 3:12 P.M. revealed the resident presented to the emergency room (ER) transported by EMS following a jump from a second story window. Resident #11was in a psychiatric facility in a locked unit and reportedly jumped out of a second story window when he wanted to leave the leave the facility. Resident #11's left ankle fracture required surgical fixation. Review of a written witness statement from HK #500 revealed he was working on the locked second floor unit on [DATE] mopping a resident room when Resident #11 approached him and tried to grab HK #500's nipples. HK #500 asked Resident #11 not to touch him. Resident #11 told HK #500 that all people liked having their nipples pinched. HK #500 told Resident #11 he did not like that and asked the resident not to touch him. Resident #11 then told HK #500 he was going to jump out the window and slammed his door. HK #500 then told an unnamed CNA, later identified as CNA #326 that Resident #11 threatened to jump out the window, but CNA #326 told HK #500 that Resident #11 would not jump. HK #500 then went to the locked unit's outside smoking patio to have a cigarette. Resident #11 then watched HK #500 through the observation window of the smoking patio. Resident #11 told HK #500 that he was watching him which made HK #500 feel uncomfortable, so the housekeeper put out his cigarette and left the unit by the elevator. HK #500 stated later he saw Resident #11 lying outside on the ground. During an interview on [DATE] at 3:23 P.M., AA #350 stated he was on the locked second floor unit on [DATE] from approximately 1:30 P.M. to 2:00 P.M. setting up pizza to be distributed to the residents. Resident #11 tried to take half of a pizza for himself, and AA #350 redirected Resident #11 who walked away from AA #350 but did not leave the common area. Resident #11 reapproached AA #350 and told him he was not afraid of him, and he was going to jump out the window. AA #350 stated he then told LPN #205 about Resident #11's threat to jump out the window. AA #350 then left the secured unit to deliver pizza to other units. AA #350 stated Resident #11 was found outside the building shortly after he left the locked unit, but he was not certain of the exact time. During an interview on [DATE] at 12:03 P.M., HK #500 stated Resident #11 attempted to touch him at approximately 1:40 P.M. Resident #11 then told HK #500 he was going to go out the window. HK #500 confirmed he reported Resident #11's threat to jump out the window to CNA #326. HK #500 said he then went to smoke a cigarette on the secured unit's locked smoke patio, but Resident #11 was staring at him which made the housekeeper uncomfortable, so HK #500 left the unit via the elevator. HK #500 stated as he was leaving the unit he saw LPN #205 in the nursing station, but the nurse was sleeping, and he didn't speak to the nurse about Resident #11's threat to jump out the window. HK #500 stated he reported to the administrative staff that he saw LPN #205 sleeping. During an interview on [DATE] at 12:22 P.M., LPN #205 stated earlier in the morning of [DATE] CNA #314 reported Resident #11 was in the wrong room and only wearing his underwear, which LPN #205 stated he documented. LPN #205 verified AA #350 told LPN #205 about Resident #11 trying to take more pizza and about the resident's statement about jumping out the window. LPN #205 stated Resident #11 made those kinds of statements about leaving the facility and jumping out a window in the past, and also that Resident #11 had broken a window on the unit in the past although he couldn't recall the specific date. LPN #205 confirmed Resident #11 had gone back to his room alone, the nurse did not go to observe and/or assess the resident. LPN #205 stated he was going to let the resident cool off. LPN #205 did not know how much time passed between AA #350 telling the nurse about Resident #11's threat and receiving the call that Resident #11 was found outside the unit. LPN #205 estimated it was about 30 minutes after the threat that Resident #11 was found on the ground outside the unit. LPN #205 denied being asleep at the time of the incident. LPN #205 stated he took his breaks on the unit and sometimes rested his eyes. LPN #205 stated he was written up later for being asleep. Observation on [DATE] at 1:00 P.M. revealed the room where Resident #11 had resided was locked and inaccessible to residents on the unit. Resident #11's window was a large stationary single pane four feet by four feet with two smaller windows, one on each side, that opened by swinging out a few inches to allow air flow, but not wide enough to allow egress. The large stationary window was broken horizontally in half, about two feet up from the lower edge. There was no evidence of a tool or piece of furniture used to break the glass. During an interview on [DATE] at 2:18 P.M., CNA #324 stated she was training CNA #326 on [DATE], because it was CNA #326's first day on the unit. They were providing incontinence care to another resident so she was not in the common area when everything with Resident #11 occurred. CNA #324 stated she felt Resident #11 had been off, and was not himself that day. CNA #324 confirmed she had told LPN #205 earlier in the day about her concerns about Resident #11's demeanor the day of the incident. During an interview on [DATE] at 2:55 P.M., CNA #314 stated he heard a resident yelling at Resident #11 to get out of his room on the morning of [DATE] and the CNA was able to redirect the resident. CNA #314 stated Resident #11 then offered to give the CNA money if he could help the resident to escape the facility. CNA #314 talked with Resident #11 and convinced him to stay at the facility. CNA #314 stated he told LPN #205 about Resident #11's desire to escape from the facility. CNA #314 stated Resident #11 had mentioned leaving the unit through a window before but had never acted on the statements. CNA #314 confirmed on [DATE] Resident #11 had been fixated on leaving the building. CNA #314 confirmed he was at lunch and not on the unit when Resident #11 jumped out the window. During an interview on [DATE] at 3:20 P.M., CNA #326 stated he was working with CNA #324 and went to get items to help a resident get up for the day. CNA #326 stated HK #500 had told him about Resident #11's sexual inappropriateness but had not mentioned Resident #11's threat to jump out the window. CNA #326 stated if he had known about Resident #11's threat to jump out the window, he would have told LPN #205 immediately and stayed with Resident #11 as per the facility training for resident safety. CNA #326 stated he felt the situation was avoidable had LPN #205 not dismissed CNA #324's concerns. CNA #326 could not confirm if LPN #205 was sleeping at the time Resident #11 jumped out the window, but CNA #326 had seen LPN #205 with his head down on the desk in the nursing station. During an interview on [DATE] at 9:00 A.M., NP #700 stated on [DATE] at approximately 1:58 P.M. she found Resident #11 lying on the ground outside the building and it appeared he had fallen from the second story out the window which was broken. NP #700 stated Resident #11 told her that he had been mad and wanted to leave the facility, and he knew the doors would not open, so he decided to go through the window. NP #700 called 911 and the resident went to the hospital. During an interview on [DATE] at 1:05 P.M., RCO #800 stated he felt the investigation of the incident involving Resident #11 could have been more thorough. RCO #800 stated he wasn't in town when the situation occurred, which made it difficult for him to assist the acting Administrator on [DATE] in the investigation. RCO #800 stated the acting Administrator on [DATE] had moved to serve as the Administrator of a sister facility when the current Administrator started working at the facility. RCO #800 felt there was a lack of supervision by LPN #205, which became more apparent with additional review. RCO #800 stated LPN #205 was terminated for failure to provide adequate quality of care to the nursing standard, because the nurse left Resident #11 left alone during a behavioral outburst. RCO #800 stated on [DATE] he re-educated the current Administrator and the acting Administrator at the time of the incident on the importance of a thorough investigation and the need to review the accuracy and information provided by staff. During an interview on [DATE] at 2:00 P.M., the Administrator stated she had not started employment with the facility until after the incident with Resident #11 occurred. The Administrator stated the original investigation which was conducted by the acting Administrator on [DATE] could have been tighter. The Administrator felt LPN #205 changed his story as the surveyor's investigation progressed and the administration asked follow-up questions. LPN #205 left the country on a planned leave of absence within a few days after [DATE] and was not available for questioning again until [DATE]. The Administrator confirmed the incident involving Resident #11 occurred due to to lack of adequate supervision of Resident #11 on [DATE]. The Administrator confirmed the facility did not have a policy regarding supervision of residents threatening to harm themselves or others. However, the facility did have training documents regarding resident safety and supervision during a behavioral emergency. The Administrator confirmed staff were trained upon hire to not leave residents unattended if they threaten to hurt themselves or others and the onboarding training document was used in staff re-education following the incident on [DATE]. Review of the facility SRI regarding the incident with Resident #11 dated [DATE] at 4:44 P.M. revealed the facility initiated an investigation of an allegation of abuse/neglect when the Resident #11 threatened to staff that he was going to break a window and jump out. The brief description of the incident indicated Resident #11 who resides in a secured male unit, who has a history of an anoxic brain injury, schizoaffective disorder, has impulsivity, and poor decision-making impairments threw himself through a plated glass window causing a fall onto the ground. The facility concluded the investigation on [DATE] at 2:09 P.M., but did not substantiate neglect, due to the resident's behaviors and impulsivity. Review of the weather report for [DATE] at 2:00 P.M. revealed a temperature of 79 degrees Fahrenheit (F), mostly clear, with no precipitation. Review of the facility policy titled Elopement Prevention and Management Unsafe Wandering and Exit Seeking Behavior dated [DATE] revealed the facility strives to prevent resident elopement and would develop a care plan and implement individualized interventions to prevent elopement. Review of the facility training document undated and untitled used for onboarding new hires and used again in the facility safety re-education initiated on [DATE] revealed a resident threatening to hurt themselves or others was a mental health crisis requiring immediate intervention. Immediate actions included the following: do not leave the resident alone, maintain continuous observation of the resident, do not leave the resident unsupervised, call for backup immediately, use a code word (Code 4-behavioral emergency) to discreetly alert staff, supervisor, and security. Further review of the document revealed even if staff felt the resident would not commit to hurting themselves or someone else, the threat should be reported immediately to the Administrator and the DON, and the resident should be placed on one-on-one supervision. This deficiency represents noncompliance at investigated under Complaint Number 2614502.