**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of Emergency Department notes, review of facility investigative information, review of facility elopement and missing resident policy and procedures and interviews, the facility failed to provide adequate supervision to prevent Resident #92, who had cognitive impairment, wandering behaviors and diagnoses of schizophrenia and dementia, from eloping from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm on 08/18/23 at approximately 8:30 P.M. when Resident #92 walked through the secured third-floor nursing unit back hallway door leading to a stairwell without staff knowledge; the door alarm sounded and was turned off by Agency Licensed Practical Nurse (LPN) #210 who failed to check to make sure all the residents residing on the secured third-floor nursing unit were on the unit and failed to notify other staff members the alarm sounded and was turned off. Resident #92 proceeded to walk down the stairs to the secured second-floor nursing unit back entrance which led to the outside. Resident #92 walked outside, the door alarm sounded, and he walked out of the facility into the parking lot. STNA #278 heard the second-floor door alarm sound and went to check the door, she saw a man walking in the parking lot, but did not think it was a facility resident and did not go outside to further investigate who the man was. Resident #92 was found by railroad tracks (approximately a quarter mile from the facility, after he experienced a fall without loss of consciousness. Resident #92 was noted to have abrasions to his left elbow and forearm and was transported to the local hospital Emergency Department on 08/18/23 around 11:30 P.M. This affected one resident (#92) of three residents reviewed for elopement. On 10/10/23 at 3:29 P.M. the Administrator, [NAME] President of Operations #209 and [NAME] President of Clinical Services #211 were notified Immediate Jeopardy began on 08/18/23 at approximately 8:30 P.M. when Resident #92 opened two facility secured doors (alarms sounded for both doors), walked out of the facility and was found by railroad tracks around 11:00 P.M. after he experienced a fall. Staff were unaware the resident had eloped from the facility at the time of the incident. The Immediate Jeopardy was removed and corrected on 08/19/23 when the facility implemented the following corrective actions: • A resident head count was completed on 8/18/2023 at 11:00 P.M. by facility staff. • On 08/18/23 Resident #92 was evaluated in the Emergency Department and no medical treatment was warranted. The resident returned to the facility on [DATE] at 5:31 P.M. and was placed on one-on-one (staff) supervision until being discharged from the facility on 08/31/23. • Within two hours of notification that Resident #92 was missing from the facility, the Administrator physically verified and visualized that all door alarms, mag locks, secure care system, window guards, and window stops were all in functioning order so no other residents were at risk for elopement. • A route cause analysis was completed on 8/19/2023 by the interdisciplinary team. The interdisciplinary team identified the root cause was Agency LPN #210 deactivated sounding door alarm to the D floor stairwell (secured third-floor nursing unit) without identifying the reason why the door was alarming. Agency LPN #210's shift ended on 08/18/23 at 11:00 P.M. The agency nurse was placed on a do not return (DNR) list following this shift. • Facility staff, including agency staff, nursing, activities, therapy, laundry, housekeeping, admissions, maintenance, and business office were educated on the proper response to facility door alarms and initial resident search expectations when door alarms were activated. • The Administrator or Designee educated all staff on missing resident policy and procedure for responding to the door alarm by 8/19/2023. • Beginning 08/19/23, the Administrator or Designee completed elopement drills on each shift for seven days and with a plan to continue to complete elopement drills monthly for four months. • The Administrator or Designee had agency staff review facility policies including elopement, missing resident procedure and the process for what to do when an alarm was activated. The education would be reviewed at the front desk or prior to entering the clinical area. The front desk was monitored by staff around the clock by 08/19/2023 to ensure all staff reviewed. • On 08/19/23 the Director of Nursing or Designee completed elopement risk assessments for all facility residents to ensure appropriate precautions and interventions were put in place. • The Director of Nursing or Designee reviewed all residents care plans who residents who were identified as high risk for elopement and revised as needed by 8/19/2023. • The facility residents identified as high risk for elopement plans of care were reviewed and revised as needed by the Director of Nursing or designee by 8/19/2023. • Director of Nursing or Designee reviewed the elopement book and updated all Resident identification (photos, name, address, phone, etcetera) information by 8/19/2023. • The Director of Nursing or Designee posted visual signs at the front, rear exit door alerting residents, families, and friends to notify staff when a resident is leaving the facility and need to sign out at the nurse's station by 8/19/2023. • The facility Administrator or Designee reviewed the Elopement Prevention-missing person policy and noted it would be updated as needed by 8/19/2023. • The VP (vice president) of Operations and VP of Clinical services reviewed the Abuse Prohibition policy by 8/19/2023. • The Administrator or Designee educated all facility staff on the Abuse Prohibition Policy by 8/19/2023. • The Administrator educated all facility staff on responding to any alarms in the building promptly and to do a visual resident observation if a resident exhibited exit seeking behavior or expressed a desire to leave LOA (leave of absence)/AMA (against medical advice) by 8/19/2023. • The Administrator or Designee completed education on the sign in, sign out procedure to residents and responsible party by 8/20/2023. • The Administrator/designee communicated with family and visitors concerning the purpose, use of alarmed exit doors, and risk for residents leaving by 8/20/2023. • The Administrator notified all resident representatives via broadcast message, educating them on the facility's process for unplanned LOA and personal outing by 8/20/2023. • The facility interdisciplinary team (IDT) conducted T Ad Hoc Quality Assessment Performance Improvement (QAPI) meeting to discuss the elopement incident and review the facility plan of correction by 08/21/2023. • Beginning 08/19/23 the facility began auditing elopement policy/review for current and agency staff. Audits consisted of three facility staff members and three agency staff members weekly for two weeks, two facility staff members and two agency staff members weekly for two weeks and one facility staff member weekly and one agency staff member for two weeks. Elopement drills would be audited every shift for seven days and then monthly times four weeks. Updates to the elopement book would be audited weekly for four weeks. All identified areas would be submitted to the Quality Assurance committee for additional analysis, review, and implementation of corrective actions, in-services, or modified policies and procedures. Findings include: Review of Resident #92's closed medical record revealed an admission date of 05/01/23 with diagnoses including schizophrenia, delusional disorder, diffuse traumatic brain injury without loss of consciousness, dementia, and epilepsy. Resident #92 was discharged from the facility on 08/31/23. Review of Resident #92's care plan dated 05/13/23 included Resident #92 was an elopement risk, wanderer related to history of attempts to leave facility unattended, impaired cognition, impaired safety awareness, new environment, traumatic brain injury (TBI), delusions and agitation. The goal developed with a target date of 08/20/23 indicated Resident #92 would not leave the facility unattended and Resident #92's safety would be maintained (through the review date). Interventions included to assess Resident #92's fall risk, identify pattern of wandering, (was wandering purposeful, aimless, or escapist, was resident looking for something, does wandering indicate the need for more exercise) and intervene as appropriate. On 07/18/23 the plan of care was updated to included safety checks every 15 minutes. initiated 07/18/23. Review of Resident #92's physician's orders revealed an order, dated 07/17/23 for every 15-minute checks for wandering. Review of Resident #92's Elopement Evaluation dated 07/13/23 revealed Resident #92 was at risk of elopement. Review of Resident #92's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #92 had severe cognitive impairment. The assessment revealed Resident #92 required supervision and a one-person (staff) physical assist for bed mobility, transfers, and locomotion on and off the unit. Resident #92 was not steady walking, but able to stabilize without staff assistance. Review of a nurse practitioner progress note, dated 08/11/23 included Resident #92 was still wandering. Further review revealed Resident #92 required a secure memory unit for safety due to TBI and bipolar disorder (psychiatry following in-house). Continue with meds (medications) and monitor. Review of a hospital emergency department note, dated 08/18/23 at 10:51 P.M. revealed Resident #92 arrived to the local hospital Emergency Department via ambulance and Emergency Medical Services (EMS) and was admitted due to a fall. Resident #92 told the Emergency Department staff he got lost on his walk and tripped over a rock and fell backwards. Resident #92 was found by train the tracks. Resident #92 stated he hit his head but denied loss of consciousness. Review of a cat scan (CT) of the head, without contrast dated 08/19/23 at 2:38 A.M. revealed Resident #92 had an unwitnessed fall with head strike and findings included no acute intracranial hemorrhage or mass effect. Review of Resident #92's medical record/progress notes revealed no written documentation related to an actual elopement on 08/18/23. Review of Resident #92's progress notes dated 08/19/23 at 6:30 A.M. revealed the local hospital Emergency Department was contacted for an update on Resident #92. The notes included Resident #92 was being discharged and was awaiting transportation. The notes did not document why Resident #92 was transported to the local hospital Emergency Department. Review of Resident #92's Elopement Evaluation dated 08/19/23 revealed Resident #92 was at risk for elopement. Review of a facility investigation included a staff interview, dated 08/19/23 from Licensed Practical Nurse (LPN) #210 who revealed she was the nurse assigned to the secured third-floor memory unit (on 08/18/23) when Resident #92 eloped from the facility. LPN #210 stated she was completing medication administration for the residents and heard the back stairwell alarm sound. LPN #210 turned the door alarm off. LPN #210 stated the State Tested Nursing Assistant (STNA) was in a resident room providing resident care. LPN #210 stated she did not look for any residents and stated she did not tell the STNA about the alarm. Review of a facility investigation included a staff interview, dated 08/19/23 from STNA #204 who was assigned to the secured third-floor memory unit (on 08/18/23) when Resident #92 eloped from the facility. STNA #204 stated Resident #92 asked about a shower, and she told him she could help him with a shower. STNA #92 revealed the nurse left the unit and STNA #204 was redirecting another resident from trying to leave the unit. LPN #210 never told STNA #204 anything about the alarm. STNA #204 stated she did not know Resident #92 was missing or off the unit until around 10:30 P.M. to 10:45 P.M. when she could not find Resident #92 to help him into bed and immediately notified LPN #210 and Supervisor #265. A staff statement, dated 08/19/23 from Supervisor #265 revealed she was told Resident #92 was missing (on 08/18/23) at 11:15 P.M. Supervisor #265 stated LPN #210 never told her she heard an alarm going off. A search was immediately initiated for Resident #92. Supervisor #265 stated she was notified by local hospital staff that Resident #92 was in the Emergency Department. A staff statement, dated 08/19/23 revealed STNA #278 was assigned to the back hallway of the second-floor nursing unit when Resident #92 eloped from the facility. STNA #278 stated she heard an alarm sounding around 8:30 P.M. for the door leading outside to the back parking lot. STNA #278 checked the door, looked outside, and saw a man walking out of the parking lot. STNA #278 indicated she did not realize it was Resident #92 because people who were not residents in the facility always stood in the parking lot or lay in the grass. Review of Resident #92's Weekly Skin assessment dated [DATE] at 10:37 P.M. revealed a new area was found. The new area was an abrasion of the left outer forearm, in-house acquired on 08/18/23. Resident #92's abrasion measured a length of 1.0 centimeter (cm), width of 1.0 cm and depth was not applicable. The area had a scab covering it and no drainage or swelling was noted. The assessment stated soap and water were used to cleanse the area and there was no dressing. Resident #92's physician and responsible party were notified. Review of Resident #92's physician's orders dated 08/20/23 at 12:52 A.M. revealed an order to cleanse left elbow and forearm abrasions with soap and water and leave open to air, every shift for wound care. Review of an interdisciplinary team (IDT) care conference note dated 08/20/23 at 2:00 P.M. revealed the note was a late entry and on 08/18/20 at 8:30 P.M. Resident #92 exited the facility without informing staff. Resident #92 was wearing a t-shirt, shorts, blue jacket and footwear and the weather was approximately 68 degrees Fahrenheit, partly cloudy. Night rounds on 08/18/23 at 11:00 P.M. revealed Resident #92 was not in his room and a search was initiated. While the facility was being searched a call was received from Resident #92's sister stating the resident was in the Emergency Department for evaluation due to a fall while out of the building. The Administrator and Director of Nursing were notified on 08/18/23 at 11:15 P.M. and Resident #92's physician was notified by the Director of Nursing upon arrival to the facility. Resident head count revealed all other residents were accounted for, door alarm system testing completed by the Administrator revealed alarms were functioning per manufacturer's specifications. Windows were assessed by the Administrator and no issues were identified. Resident #92 returned to the facility on [DATE] via ambulance. 08/19/23. The Director of Nursing interviewed Resident #92 to determine purpose for leaving the facility and Resident #92 stated I was going to work. No psychosocial or emotional distress noted at the time of the assessment. The facility provided information from a public records request as part of their investigation. The record (requested by the facility on 08/21/23) included Resident #92 was picked up in the vicinity of a local road by railroad tracks and brought to the local hospital on [DATE] at approximately 11:00 P.M. Interview on 10/10/23 at 1:55 P.M. with [NAME] President of Clinical Services (VPCS) #211 verified Resident #92 eloped from the facility on 08/18/23. VPCS #211 stated staff were interviewed about when they last saw Resident #92 and when door alarms were heard. VPCS #211 indicated she was not in the facility at the time of the elopement but from the interviews it was determined Resident #92 was last seen on 08/18/23 at approximately 8:30 P.M. VPCS #211 stated Resident #92's sister called the facility regarding Resident #92's elopement around 10:30 P.M. to 11:00 P.M. which was about the same time Resident #92 was found to be missing (by staff). VPCS #211 stated Resident #92 resided on the third-floor secured nursing unit and residents did not wear wander guards. VPCS #211 revealed a code was needed to exit two stairwells which could be used to enter and exit the third-floor secured nursing unit. VPCS #211 indicated there was an elevator which was used to enter and exit the third-floor secured nursing unit, and a code was needed to use the elevator. VPCS #211 stated both stairwells had a 15-second egress and would alarm immediately and open after 15 seconds if an attempt was made to open the door without a code. VPCS #211 stated Licensed Practical Nurse (LPN) #210 was an agency nurse working on the secured third-floor nursing unit on 08/18/23 when Resident #92 eloped from the facility. VPCS #211 stated LPN #210 heard a door alarm and turned it off without notifying anyone. VPCS #211 stated she did not know why LPN #210 did not tell anyone or initiate a resident head count when she heard the alarm. VPCS #211 stated Resident #92 walked down a flight of stairs from the third-floor secured nursing unit back entry to the second floor back entry which also had an alarm and opened after 15-seconds to the outside at ground level. VPCS #211 stated the second-floor entrance door alarmed, and opened after 15 seconds, and Resident #92 walked out the second floor back entrance to the outside. VPCS #211 revealed an aide heard the alarm and turned off the alarm without realizing Resident #92 left the facility via the second-floor entrance. VPCS #211 stated the aide saw someone standing in the parking lot but did not realize the person was Resident #92. Interview on 10/11/23 at 12:36 P.M. of State Tested Nursing Assistant (STNA) #204 revealed 08/18/23 was the first time she worked on the secured memory unit. STNA #204 stated during the day shift on 08/18/23 she was assigned to a different nursing unit, and stayed after her regular shift ended at 7:00 P.M. to work on the secured nursing unit because the secured memory unit needed coverage from 7:00 P.M. until 11:00 P.M. STNA #204 stated she did not know the residents on the secured nursing unit and an agency nurse she did not know was also assigned to the secured memory care unit. STNA #204 stated the agency nurse did not give her a thorough report regarding which residents were elopement risks. STNA #204 stated she was completing documentation on a resident who was a fall risk, and the agency nurse left the unit for a break. STNA #204 stated the nurse came back from her break, used the back entrance of the secured nursing unit, and did not mention an alarm was sounding when she came back. STNA #204 stated she discovered Resident #92 was missing around 10:30 P.M. and could not remember the time she last saw Resident #92. STNA #204 indicated after Resident #92 was found to be missing the agency nurse told her when she came back from her break the door for the rear entrance of the secured nursing unit was alarming and she turned the alarm off. STNA #204 stated the agency nurse told her she did not think a resident eloped when the door was alarming and that was why she did not say anything. STNA #204 stated she completed rounds on the residents she was assigned to every two hours and did not remember Resident #92 seeking to leave the unit. STNA #204 revealed while they were searching for Resident #92 someone from the hospital emergency department called the facility and told them Resident #92 was being evaluated at the hospital. Review of the facility undated policy titled Missing Resident revealed the purpose was to ensure missing residents were located quickly. A search of all rooms in the facility would be done if a resident was thought to be missing. Assign two personnel to check the area immediately outside the facility. Personnel should go around the facility in opposite directions. When they meet, they should return inside for reassignment. Review of the facility undated policy titled Elopement Prevention revealed it was the goal of the facility to provide a safe environment for all residents while using the least restrictive measures possible. Elopement occurred when a resident left the premises or safe area without authorization and, or necessary supervision to do so. A resident who left a safe area might be at risk of heat or cold exposure, dehydration, and, or other medical complications, drowning, or being struck by a motor vehicle. Residents would be assessed upon admission, quarterly, and with a significant change in condition using the facility designated assessment form to determine whether the resident was at risk for elopement. Once the risk assessment was completed, the IDT (interdisciplinary team) would review the assessment and make the determination if the resident should be identified at risk for wandering and, or elopement. The IDT would document their decision accordingly on the format provided and proceed with determining interventions to keep the resident safe. This deficiency represents non-compliance investigated under Complaint Number OH00146796.