**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews with staff and residents, review of the medical record, and review of the facility Elopement Risk Assessment Policy and Procedure, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident #55), who had severe cognitive impairment, a legal guardian and exit seeking behaviors. This resulted in Immediate Jeopardy on 04/22/19 at approximately 9:45 P.M. when Resident #55 exited the facility without staff knowledge. The likelihood of Actual Harm that is Immediate Jeopardy occurred as Resident #55, dressed in dark clothing, was seen pushing his wheelchair along a busy, two lane road at approximately 9:50 P.M. by a staff person driving to work. This affected one of four residents reviewed for elopement risk and wandering behaviors. The facility has identified 25 residents at risk for elopement. The facility census was 91 residents. On 04/25/19 at 1:00 P.M., the Administrator and Corporate Nurse were notified Immediate Jeopardy began on 04/22/19 at 9:45 P.M. when Resident #55, who was at risk for elopement and exhibited a desire to leave the facility, went out the front door of the facility. The Immediate Jeopardy was removed on 04/26/19 when the facility implemented the following corrective actions: • On 04/22/19 at approximately 9:52 P.M., Licensed Practical Nurse (LPN) #416 received a telephone call from an employee driving to work to report someone who looked like a resident was walking down the street. LPN #416 initiated the facility elopement policy which included staff searching the facility and surrounding area and discovered Resident #55 was not inside the facility. • On 04/22/19 at 10:03 P.M., Resident #55 was returned by staff to the facility and assessed to have no injury. Resident #55 indicated he went out the front door of the facility. He was immediately placed on one-to-one supervision by staff, and his physician and guardian were notified. • On 04/22/19 from 10:03 P.M. until 10:30 P.M. the front door was continually monitored by State Tested Nursing Assistant (STNA) #404, Registered Nurse (RN) #434, or Licensed Practical Nurse (LPN) #406 until Director of Maintenance (DM) #425 arrived to reset the alarm code on the front door. • On 04/22/19 at approximately 10:30 P.M., DM #425 discovered the front door was not secured when entering the facility. DM #425 reset the alarm code on the door and checked all remaining doors to ensure they closed and were secured and/or alarmed when opened. • On 04/22/19 at 10:30 P.M., DM #425 began door code function checks, which will continue daily indefinitely. • On 04/22/19 at 10:45 P.M. the Administrator, DM #425, and RN #450 began in-servicing all second and third shift staff on the facility Elopement Policy and Procedure. • On 04/23/19 at 7:54 A.M., Resident #55 was moved to the secured unit. • On 04/23/19 at 1:59 P.M., RN #600 completed elopement reassessments of all facility residents, with care plans and interventions updated as needed. Twenty-four residents were found to be at risk for elopement and all but two (Residents #21 and #62) resided on the secured unit. There was no evidence that Residents #21 and #62 had made attempts to exit the building, and care plans were in place with interventions to prevent elopement. • On 04/23/19, RN #450 reviewed and updated the resident identification books for those residents who were at risk for elopement (Happy Feet Club). • On 04/23/19, the contracted door security company inspected all doors in the facility, including the front door. The door security system was cleared and reset to ensure no additional codes provided to staff or emergency personnel would be able to override the door security code. • On 04/24/19 at 7:30 P.M., an elopement drill was conducted with 18 staff members participating. • On 04/25/19 by 10:10 P.M., the Administrator and DON had in-serviced one RN, nine LPNs, 25 STNAs, five housekeeping staff, eight dietary staff, two activity staff, one social service, five therapy, one receptionist, one maintenance staff, and nine administrative staff either in person or by phone, regarding the facility policy and procedure for a missing resident/elopement; checking residents for safety every two hours; and reporting suspicious or unsafe activity to the Administrator, DON, or Nursing Supervisor immediately. In-services will continue until all remaining 19 staff are in-serviced as they return to work. • On 04/26/19 at 2:30 P.M., the contracted door security company installed a mag lock on the social service office exit door and a new security key pad to control the exit access to the parking lot from the stairwell side exit door. Although the Immediate Jeopardy was removed on 04/26/19, the deficiency remains at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing with staff in-services and was in the process of monitoring staff and exit doors to ensure compliance and determine if further action is required. Findings include: Review of Resident #55's medical record revealed he was admitted to the facility from the hospital on [DATE] with diagnoses including alcohol related dementia with delirium, alcohol related seizure disorder, alcohol dependence, alcoholic peripheral neuropathy, altered mental status, unsteadiness, muscle weakness and visual hallucinations. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #55 was severely cognitively impaired; he did not have behaviors; and he required limited to extensive assistance of staff for activities of daily living. An elopement risk assessment completed by RN #605 on 03/28/19 indicated Resident #55 was at high risk for elopement due to his diagnoses of alcoholism and delusions, as well as making verbal statements that he wanted to leave. However, at that time that he was unable to ambulate or propel himself in a chair or wheelchair. A progress note written by LPN #406 on 04/09/19 at 2:57 A.M. revealed the resident took the elevator to the lower level saying he was looking for the party he had to go to and was redirected back to his unit. On 04/13/19 at 5:00 P.M., LPN #610 wrote in a progress note that Resident #55 was again on the elevator, and a telephone call from the elevator company was received saying that the resident used the phone in the elevator, saying he was going to a party. A progress note written by RN #615 on 04/14/19 at 4:25 A.M. revealed the resident was wandering with a wheeled walker throughout the shift and needed constant re-direction and reassurance. The note indicated the resident was exit seeking and said he wanted to go get a beer and attempted to go out the door leading to the patio. He became combative initially with redirection but was able to be assisted to bed. A subsequent elopement assessment completed by RN #620 dated 04/15/19 revealed Resident #55 was still at high risk for elopement and was now able to ambulate or propel himself in a wheelchair. The assessment indicated the resident was staying near windows or exit doors. Resident #55's care plan dated 04/15/19 through 07/17/19 revealed he was at risk for elopement due to his dementia and exit seeking behaviors. Interventions included completing a resident identity sheet due to risk factors; informing facility staff of potential for elopement; and checking the resident frequently and re-directing him from exit doors as needed. Other interventions included encouraging activity involvement; attempting to determine the resident's needs; and try to convince him that there is no need to look outside. A progress note written by Licensed Social Worker (LSW) #625 on 04/17/19 at 12:47 P.M. revealed the social worker spoke with the resident's mother who was his guardian, and she indicated she did not feel the resident should be living independently. The surveyor observed Resident #55 on 04/22/19 throughout the day. He was mobile in his wheelchair in the hall near his room. He was pleasant but confused when the surveyor attempted to speak with him around 3:00 P.M. A progress note written by RN #434 on 04/22/19 at 11:07 P.M. revealed the resident was seen outside the facility. The note indicated a staff member brought him back and no concerns were noted. The resident's guardian and the physician were notified. On 04/23/19 at 1:30 P.M., interview with Resident #55 revealed he was confused but pleasant. He said he had only been at the facility for about 35 minutes, and said he worked all day at the big house. He was unsure of where his room was, saying he did not live at the facility and was waiting for someone to pick him up. Interview with the Administrator on 04/23/19 at 4:20 P.M. confirmed Resident #55 had been found outside the facility on 04/22/19. She said an investigation was in progress, including interviews with staff. She said STNA #414 was coming to work and observed Resident #55 on the road in front of the facility about 0.25 miles away. She said the resident was confused and could not say exactly how he was able to leave the building but said he went out the front door. The Administrator said when DM #425 came to the facility on [DATE] around 10:30 P.M, he found the front door of the building, which had a key pad coded entry, was unsecured and open. She said the key pad code for the door was then reset at 10:30 P.M., and the door was locking when closed. The Administrator said an investigation was in process to determine how the door became unlocked, and Resident #55 was moved to the secured unit on 04/23/19 at 8:00 A.M. On 04/23/19, the facility began an audit of new admissions or re-admissions to the facility to review the Clinical admission Documentation Observation for the Elopement score and ensure the appropriate protocol had been implemented. Nursing progress notes for all residents would also be reviewed to ensure any exit seeking or wandering behaviors would be addressed with proper interventions implemented. These audits will be completed daily Monday through Friday during the clinical meeting by the Nursing Management Team and Social Services staff for four weeks then would become part of the quality assurance program. Charge nurses will be responsible to notify administrative staff of any new exit seeking behaviors by any resident that occurred Friday through Monday morning An interview with STNA #404 on 04/24/19 at 6:10 P.M. revealed she worked on 04/22/19. She said she was familiar with Resident #55 who needed redirection frequently and was usually confused and wandered in his wheelchair in the hallways and at the front lobby of the facility, at times talking about leaving the facility. She said on 04/22/19 she saw the resident about 9:40 P.M. or 9:45 P.M. as she was leaving the building to go on a dinner break. She said the resident was not in the immediate area of the door. She said she entered the code to get out of the door and was not sure that the door was locked. She said she went to her car and returned around 10:00 P.M., when she was told a resident was missing. She went out again to her car and drove around the facility to help search for the resident. She said she was only outside a couple minutes when she was called by another staff member who said the resident was found. On 04/24/19 at 6:30 P.M., interview with LPN #406 revealed she was the nurse on duty on 04/22/19. She said Resident #55 frequently needed redirection but generally responded positively to staff intervention. She said around 9:35 P.M. or 9:40 P.M. she saw Resident #55 in the hall near his room. She said STNA #404 had gone on her break, and STNA # 401 was in the nurse's station when she went into a resident's room to do a dressing change. She said about 15 minutes later, she heard the elopement call over the intercom indicating a resident was missing. She quickly finished her task and exited the room and saw STNA #401 looking in the hall for the missing resident, so she went outside. She said she was not outside more than a couple minutes when she got a phone call that the resident had been found. She returned to the nursing unit and was there to greet Resident #55 when he returned with staff. She said Resident #55 said he left the facility out of the front door and was unclear as to where he was going. Resident #55 was not injured. She said Resident #55 was placed on one-to-one monitoring after he returned to the facility. An interview with STNA #401 on 04/25/19 at 9:00 A.M. revealed she was assigned to the unit with STNA #404 on 04/22/19. She stated STNA #404 went on a break and she was at the nurses station when LPN #406 went into in a resident room to change a dressing. She said Resident #55 was in his doorway about 9:45 P.M. when a call light went off, so she went to answer it. STNA #401 went into another room on her way back to the nurse's station and then heard the call about a missing resident. She said she was told to go outside and look for the resident, so she did, and within a few minutes she was told the resident had been found. STNA #401 said she talked to Resident #55 when he returned, and said he thought the whole incident was not a big deal and was funny. STNA #401 said Resident #55 was always able to be redirected away from doors and she assumed the front doors were secured. An interview with STNA #414 on 04/25/19 at 9:15 A.M. revealed as she was driving to work on 04/22/19 about 9:55 P.M., she saw someone walking away from the facility. She said the person was pushing a wheelchair and was walking facing traffic on the pavement on the side of the road, but not in the roadway. She said by the time she recognized the person as a resident, she was already at the facility, so she pulled in and called to let them know to check for all residents, as she thought she saw a resident walking on the road outside. She said she did not know the name of the resident because she works nights, the resident was new, and she did not work on that unit. However, she recognized the resident from the facility. STNA #414 said she did not go into the facility right away because it was not actually time for her shift. She said she usually comes early to drink coffee and relax in her car before going in to start her shift. Review of the statement by STNA #414, dated 04/24/19, revealed while sitting in the parking lot after making the phone call, she saw staff members coming out the facility to search for the resident, including STNA #401, and STNA #410 and LPN #412 who got into a car and drove in the direction of the resident. LPN #416 was not able to be reached by phone. Review of her statement dated 04/24/19 revealed she answered the facility phone when STNA #414 called in to say she saw a resident outside the facility. LPN #416 indicated she did not ask which direction the resident was walking. She indicated she told STNA #410 and LPN #412 to go look for the resident. LPN #416 then tried to reach LPN #406 who did not answer her phone. She then called the overhead page to alert staff of a missing resident (Dr. Walker) and called LPN #430 who helped her identify the resident missing as Resident #55. An interview with LPN #412 on 04/25/19 1:48 P.M. revealed he was newly employed by the facility and 04/22/19 was one of his first days. He said when he heard a resident had been seen outside the facility, and he was sure that the residents on the secured unit were accounted for, he left with STNA #410 to go look for the resident. LPN #412 said the resident was found seated in his wheelchair self-propelling along the road not far from the facility. He said STNA #410, who was driving, turned around and stopped near the resident, who appeared unharmed and was cooperative in getting into the car. LPN #412 said Resident #55 told him he was going home but was agreeable to returning to the facility. Review of STNA #410's statement, dated 04/25/19, revealed she was instructed by LPN #416 to go look for the resident when it was reported that a resident had possibly left the facility. She went with LPN #412 who saw the resident sitting in his wheelchair near a school down the street from the facility. STNA #410 said Resident #55 was cooperative and they were able to return him easily to the facility. An interview with DM #425 on 04/25/19 revealed the administrator notified him of the incident on 04/22/19 around 10:09 P.M. and he was asked to go to the facility to check on the doors. He said he arrived about 10:30 P.M. and upon entering the front door of the building, noted the alarm was not set and he was able to open the front door without the alarm sounding. He immediately re-set the alarm from the keypad inside the door. He said he did not check if the front door, when opened from inside the facility, was locked but had been told that it was open. Observation and interview with Resident #55 on 04/25/19 at 3:15 P.M. revealed he was on the secured unit, standing in the common area with his walker. He was dressed neatly and was confused. He denied concerns but said he was thinking he should leave and go check on his car and dog. He was encouraged to remain at the facility and was agreeable. Resident #55 was not actively exit seeking at that time and was able to point toward his room and talk about what he had for lunch. The administrator, director of nursing, social worker and three registered nurses, who were part of the Nursing Management Team, were in-serviced on 04/26/19 by the regional nurse. Education for the charge nurses was started on 04/26/19 and would continue until all were educated. On 04/26/19 between 10:30 A.M. and 11:30 A.M., interview with three LPNs, four STNAs, one laundry staff, and one receptionist revealed they were knowledgeable regarding the facility policy and procedure for elopement, including the identification of residents at risk for elopement (Happy Feet Club), use of the door key pad security system, what to do if the door security system didn't function properly, the code for elopement, and reporting anything unusual to the Administrator, DON, or Nursing Supervisor immediately. Interview with the administrator on 04/26/19 at 10:36 A.M. confirmed an interview statement written by Occupational Therapist (OT) #428, which indicated she observed Resident #55 in the administrative office area on 04/22/19 at 9:30 P.M., and she redirected the resident out of the area. The administrator verified that if Resident #55 had been in that area, it would have indicated the French doors to the administrative offices were not locked. She further verified although it was unknown how the resident exited the building, he most likely exited through the front door, but may have had access to the unlocked, unsecured door off the administrative area and could have exited there. Observation on 04/26/19 at 2:30 P.M. revealed the contracted door security company was completing the installation of a mag lock on the social service office exit door and a new security key pad to control the exit access to the parking lot from the stairwell side exit door. These exit doors were accessible from the front lobby through the French doors leading into the administrative offices. Review of the facility's Elopement Risk Assessment Policy and Procedure, updated on 02/23/18, revealed all residents should be assessed on admission to the facility. If a resident was determined to be low risk, they would be monitored and reassessed if they had a significant change to their condition. If a resident was assessed as moderate or high risk, they would have a care plan to address their risk factors and have a resident identification form completed and put in a notebook at each of the nurse's station and at the receptionist's desk.