**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interviews, review of the facility's quality assurance investigation, review of hospital documentation and reports, and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of a resident, without staff knowledge, who was cognitively impaired and assessed as being at risk for elopement. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when Resident #136 eloped from the facility and the resident was found by a staff family member 600 feet away from the facility near a highway that had a 55 Miles Per Hour (MPH) speed limit. This affected one (Resident #136) of three residents reviewed of a total of seven identified by the facility as being at risk for elopement. The facility census was 134. On [DATE] at 1:47 P.M., the Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON) #610, and Clinical Operations Director #333 were notified Immediate Jeopardy began on [DATE] at 8:20 P.M., when Resident #136 was not provided adequate supervision and eloped from the facility. Resident #136 was assessed as being at risk for wandering and elopement. Resident #136 had a history of dementia and behaviors including exit seeking. On [DATE] around 7:20 P.M., the facility staff were unable to locate Resident #136 after completing a head count of all residents on the secured memory care unit. The resident was located approximately 600 feet from the facility after completing a search of the grounds and the surrounding area at 8:23 P.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 7:20 P.M., State Tested Nursing Assistant (STNA) #111 last saw Resident #136 on [NAME] Hall unit. • On [DATE] at 7:40 P.M., STNA #111 stated he was unable to locate Resident #136. • On [DATE] at 7:40 P.M., Registered Nurse (RN) #399 was notified and implemented the Wandering/Missing Policy. • On [DATE] from 7:42 P.M. to 7:50 P.M., Staff Notifications were made to the Administrator by RN #399, and notification to the DON, Maintenance Director #900, and Staffing Coordinator #140 were made by Administrator. • On [DATE] from 7:40 P.M. to 8:04 P.M., staff searched inside and outside the building and surrounding locations by all available staff, from all departments. Minimal staff were left on each unit to manage care needs. • On [DATE] at 8:00 P.M., all other residents were verified to be in the facility by RN #399, LPN #501, LPN #222, and LPN #849. • On [DATE] at 8:04 P.M., police notifications were made by the Administrator. • On [DATE] from 8:04 P.M. to 8:20 P.M., the search for Resident #136 was ongoing. • On [DATE] at 8:23 P.M., Resident #136 was found by the husband of Staff Coordinator #140. • On [DATE] from 8:23 P.M. to 9:03 P.M., Resident #136 was initially assessed, returned to the facility, and more fully assessed by Licensed Practical Nurse (LPN) #250, the DON and ADON #610. • On [DATE] at 8:40 P.M., Doors on [NAME] Hall were checked and found to be operational by Maintenance Director #900. The gate was checked on the secure courtyard and was found to be operational; however, could be opened if it was pushed with enough force. • On [DATE] at 8:40 P.M., [NAME] Hall door audits began and will continue daily for one week, and then weekly for four weeks. These audits will be completed by Maintenance Director #900 or his designee. Results will be provided to the Quality Assurance Team for review. • On [DATE] at 9:03 P.M., Physician #89 was contacted and communicated status of events and assessments for Resident #136 by the DON, and an order was received to send the resident to the emergency room (ER) for evaluation and treatment. • On [DATE] at 9:05 P.M., [NAME] Life Squad was contacted by LPN #250. The squad arrived at approximately 9:09 P.M. and assumed responsibility of Resident #136. • On [DATE] at 9:15 P.M., in-servicing of staff was started for Review of Wandering/Missing Resident Policy by the Administrator and was completed by all staff on [DATE]. • On [DATE], the power supply to the exterior courtyard gate was replaced. • On [DATE], audits for residents deemed at high risk for elopement were completed and care plans reviewed per the DON and/or designee. This included seven residents (#17, #64, #66, #94, #107, #111, and #132) identified at high risk. No new concerns were identified. • On [DATE] at approximately 11:00 A.M., the facility placed a staff monitor at the end of [NAME] Hall and will continue around the clock until the new door system is installed. • On [DATE] and completed on [DATE], staff were interviewed to determine if there are any exit seeking behaviors for residents who are identified at high risk to elope. The interviews will be for each shift for one week and then once daily for an additional week. Once completed, the results will be reviewed by the Quality Assurance Team. • On [DATE] at 11:50 A.M., interviews with STNA #776, LPN #779, and RN #777 revealed they have all been reeducated on the Elopement Policy and the residents who are at risk for elopement. • On [DATE] at 12:45 P.M., observation of the facility revealed an outside contractor is providing maintenance to the outside door on the secured unit. STNA #776 is seated six feet from the door and monitoring. Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring for on-going compliance. Findings include: Medical record review revealed Resident #136 was admitted to the facility on [DATE] with diagnoses including hypertension, falls, dementia, and unspecified psychosis with delusions. Further Review of Resident #136's record revealed she was discharged to the hospital on [DATE]. Review of Resident #136's elopement risk assessment dated [DATE] revealed the resident was physically capable of leaving the facility, the resident was confused to time and place and resident wandered, roamed and paced. The resident was also assessed to be a high risk for elopement. Review of Resident #136's admission nursing observation, dated [DATE], revealed Resident #136 was alert and oriented to person. Resident #136 was noted to be verbally incomprehensible and required limited assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and walking in room and locomotion on the unit. Resident #136 also required supervision with eating. Review of Resident #136's physician order dated [DATE] revealed Resident #136 was to have a Roam Alert bracelet in place and to check placement and function daily, every shift. Review of Resident #136's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to have severe cognitive impairment and required limited assistance with bed mobility, transfers, eating, locomotion on and off the unit and walking in the room and in the corridor. Resident #136 also required limited assistance with dressing, toileting and personal hygiene and was reported to wander during the [DATE] MDS. Review of Resident #136's elopement care plan dated [DATE] revealed Resident #136 was at risk for elopement and wandering due to dementia. Interventions included Roam Alert bracelet, identifying patterns of wandering, provide structured activities, monitor for fatigue and weight loss, and distract resident from wandering with diversions. Review of Resident #136's cognition care plan dated [DATE] revealed Resident #136 was at risk for alterations in thought process due to dementia. Interventions included activities staff will provide resident with a calendar of events and invite the resident to attend those of interest, administer medications as ordered, allow ample time for resident to complete tasks, allow the resident the opportunity to make choices regarding daily routine, allow resident to complete as much personal hygiene and oral care as possible and always explain the activity being performed with a gentle voice. Review of Resident #136's progress note dated [DATE] at 5:10 P.M. revealed the facility received reports from Resident #136's hospice provider that the resident has a tendency to wander. A Roam Alert bracelet was placed. Review of Resident #136's progress note dated [DATE] at 5:12 A.M. revealed Resident #136 was found by staff to be wandering but was redirected back to her room with a snack. Review of Resident #136's progress note dated [DATE] at 3:24 A.M. revealed Resident #136 had wandered off the unit after being up wandering most of the night. Review of Resident #136's Social Services note dated [DATE] at 2:05 P.M. revealed Resident #136 has an extensive history of wandering prior to residing in the facility. The notes documented a discussion with the spouse of Resident #136 resulted in a decision to move the resident to a secured and locked unit with a room change due to recent wandering episodes. Review of Resident #136's progress note dated [DATE] at 8:23 P.M. revealed Resident #136 was located outside of the facility grounds after she had left the facility unaccompanied by staff. The resident was found by the husband of Staffing Coordinator #140, after a search of the area was initiated. The resident was located lying on the ground with a hematoma to the left side of her forehead. The resident was sent to the hospital for evaluation with transport arriving at 9:20 P.M. Review of Resident #136's hospital records revealed an admission date to the hospital on [DATE] to the emergency department trauma center. Hospital notes documented Resident #136 was admitted with diagnoses including parenchymal hematoma/contusion of the right inferior frontal lobe, a subarachnoid hemorrhage of the right frontal lobe, a left frontotemporal scalp hematoma, fractures of the posterior left 8th rib and non-displaced anterior 5-6 rib fractures, as well as left lateral 7-10 rib fractures. The resident also was diagnosed with a fracture of the left para symphyseal pubis and left inferior pubic ramus. Review of the Quality Assurance Note dated [DATE] revealed Resident #136 was last seen on her unit at approximately 7:20 P.M. A search of the unit was completed with RN #399 being notified. Staff implemented the Missing/Wandering Resident Policy at 8:40 P.M. The Administrator and Director of Nursing were notified. A search of the grounds and surrounding areas began, with Police being notified at 8:04 P.M. to assist in the search. At 8:20 P.M., Resident #136 was found on a gravel driveway of a neighbor adjacent to the facility. The note documented the facility suspects the resident eloped from the exit door at the end of the secured hallway by pushing the door open to the courtyard. The resident was able to exit the gated courtyard by pushing through a magnetic lock on the courtyard gate. The resident was assessed to have a hematoma to the left side of her forehead upon discovery. The resident was returned to the facility at approximately 8:40 P.M. by facility transport. Interview with the Director of Nursing on [DATE] at 9:30 A.M. revealed Resident #136 eloped from the facility on [DATE]. She stated she suspects the resident had walked out of the door to the outside courtyard and proceeded to leave the gated courtyard through a magnetically locked gate. She stated the resident then looped around the front of the building and driveway until she ended up in the driveway of a nearby, adjacent home. No outdoor cameras captured the resident eloping through the main front door as that is where the camera is located. She stated the resident was found by the husband of Staffing Coordinator #140, and nursing was notified. LPN #250 then assessed the resident to have a hematoma to her left forehead, and no other complaints of pain. She stated that after the resident was returned to the facility, staff were helping the resident clean up, when Resident #136 began complaining of hip pain at that time. She stated all notifications were made, and the resident was sent to the hospital at approximately 9:20 P.M. for evaluation. Interview with Maintenance Director #900 on [DATE] at 9:30 A.M. revealed the resident had more than likely eloped through the courtyard door on [DATE]. He stated he had checked function of the door and it was functioning properly that evening. He stated he also checked the function of the magnetic lock on the courtyard gate, which was found with a weak charge, which allowed for the gate to be pushed open easily. He stated a new door was ordered and scheduled to be installed the morning of [DATE]. He also stated he had adjusted the charge on the magnetic lock which is now functioning at full strength as of [DATE]. Interview with RN #399 on [DATE] at 9:30 A.M. revealed she was alerted to a possible elopement of Resident #136 on [DATE]. She stated the resident was an elopement risk and she alerted the Administrator and Director of Nursing at approximately 7:40 P.M. that evening. Interview on [DATE] at 10:29 A.M. with STNA #111 revealed he was working on the secured unit on [DATE]. He stated he last saw Resident #136 around 7:10 P.M. when she was in the resident lounge area. He stated he then went to assist another resident into her wheelchair and provide care. He stated at 7:20 P.M., another STNA arrived on the unit from her lunch break, and they completed a head count of all residents on the secured unit as he was leaving for his lunch break. He stated Resident #136 could not be located as the head count was one short. He stated no alarms were sounding that he could recall, and the exit door to the courtyard was closed. He then stated he notified RN #399 they could not locate Resident #136, and the Missing/Elopement Policy was enacted at 8:40 P.M. He stated he was not aware Resident #136 was at risk for elopement. Telephone Interview with the daughter of Resident #136 on [DATE] at 11:30 A.M. revealed the resident expired in the hospital on [DATE] with multiple brain bleeds, pelvic fractures, and rib fractures. She stated the death is being reported as an accidental death as a result of a fall. Observation of the facility on [DATE] at 1:15 P.M. revealed the exterior door on the secured unit opened freely to the courtyard with an alarm sounding through the hall. The alarm was located in the middle of the hall, with the shut off switch approximately two feet from the ceiling and must be manually switched off. The courtyard gate could not be opened due to the magnetic lock on the gate during this observation. STNA #776 is currently seated by the door to monitor for any resident who may try to elope. Review of an undated list of residents with Wander Guards revealed Residents #17, #64, #66, #94, #107, #111 and #132 had Wander Guards in place as these residents remain at risk for elopement. Review of the facility's wandering and elopement policy dated [DATE] revealed staff shall promptly report any resident who leaves or attempts to leave to the Charge Nurse or Director of Nursing. In the event an employee discovers a resident is missing from the facility, they should determine whether the resident is on a leave or pass; an immediate search of the facility if not authorized to leave; if the resident is not located in the facility, all parties will be notified including Administrator, DON, physician, law enforcement, and volunteer agencies as necessary; provide search teams with identification information and initiate an extensive search of the surrounding area. This deficiency represents noncompliance for Complaint Numbers OH00140058 and OH00140048.