**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documents, resident interview, and staff interview, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge). This failure created an immediate jeopardy situation for one out of 195 residents (Resident R1). Findings include: The facility Wanderer management program policy last reviewed on 1/9/23, indicated that the facility will provide safety measures for all residents who are deemed to be in need of additional safety measures including wander management. Elopement occurs when a resident who needs supervision leaves a safe area without supervision. The resident should have interventions in their comprehensive care plan to address elopement, residents should be assessed for safety, and physician orders written directing what level of access within the facility for which a resident is determined to be safe without direct supervision. Nurse aide staff will account for all monitored residents at the beginning of each shift, every two hours during the shift, and at the end of the shift. Review of Resident R1's admission record indicated he was admitted on [DATE], with diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), hypertension (a condition impacting blood circulation through the heart related to poor pressure), chronic obstructive pulmonary disease (COPD-a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), cerebral infarction (a blockage to the brain resulting loss of blood and oxygen), chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), and Strabismus (a vision disorder in which the eye does not properly align). A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1's MDS assessment dated [DATE], Section C0500-BIMS screening indicated a score of 13 revealing that Resident R1 was alert and oriented to person, place and situation. Review of Resident R1's physician orders dated 7/6/23, resident may move about units without supervision; supervision for off campus. Review of Resident R1's admissions documentation indicated that his home address was 1.2 miles from the nursing facility. Review of Resident R1's clinical nurse notes dated 8/7/23, indicated he exited the building via the front door, wander guard applied to right wrist and Resident R1 was educated. Thorough review of Resident R1's clinical record indicated no additional information related to this elopement. Review of Resident R1's care plan dated 8/8/23, indicated that he will not elope from the unit or building. Provide routine monitoring, wander guard at all times, checks every shift and as needed. Review of Resident R1's elopement evaluation on 8/30/23, indicated that Resident R1 attempted to go outside to leave without alerting staff on 8/7/23. The Elopement evaluation indicated Resident R1 displayed behaviors indicating an attempt to leave, he made statements questioning the need to be at the nursing home. Review of Resident R1's clinical nurse note dated 10/1/23, indicated Nurse aide (NA) doing wander guard checks found that Resident R1 was not in his room and could not be found on the nurse unit. These documents were not part of the clinical record. Review of Resident R1's safety event/elopement incident note dated 10/2/23, indicted that on 9/30/23 at 2:38 a.m. it was discovered that Resident R1 was not in his room. Security notified and facility check was done. Security camera reviewed and observed Resident R1 leave the 4B nurse unit fully dressed, exited through the ambulance door and walked through the parking lot. Family was called. Police were notified and provided address as Resident R1 expressed desire to return home. Facility staff continued search for Resident R1. Police contacted facility and reported that Resident R1 was located at his home address. Resident R1 returned at 4:28 a.m. and was assessed with no injuries found. The wander guard was found with the resident, did not indicate if the wanderguard was on the original placement area of Resident R1's body. The National Weather Service records indicated that the overnight temperature on 9/30/23 into 10/1/23 was 56 degrees Farenheit. Review of facility submitted documents dated 10/2/23, indicated that Resident R1 was discovered not present in his room at 2:38 a.m. on 10/1/23. Nursing staff and security will be re-educated on wander guard system and safety checks. Review of Facility meeting minutes dated 10/3/23, indicated that the facility implemented accountability checks on 10/3/23 as a part of corrective actions. However, the corrective actions did not include whole house re-training for all nursing staff and retraining for security staff. Review of facility investigation documents dated 10/3/23, indicated that Nurse Aide (NA) Employee E8 documented that she provided care to Resident R1 on 10/1/23, at 12:05 a.m., however, Resident R 1 exited the facility at 8:52 p.m., on 9/30/23, three hours and 13 minutes prior. Security Guard Employee E7 provided a statement that he silenced the alarm on 9/30/23, and did not see a resident walk out of the ambulance exit. Review of all facility documentation revealed that there was no additional information available in the clinical record or in the facility investigation surrounding the elopement of Resident R1. During a review of security footage with Maintenance Supervisor Employee E1 and Security Chief Officer Employee E2 on 10/10/23, at 10:20 a.m. the following was observed: Footage starts at 9/30/23, at 8:23 p.m. Resident R1 observed fully clothed, with a jacket and a hat, getting on elevator at 8:23 p.m. At 8:24 p.m. Resident R1 exits the elevator to the first floor. Resident R1 went outside to the smoking area at 8:25 p.m. Resident R1 was observed without a walker or cane. Resident R1 spoke to staff in smoking area. At 8:40 p.m. Resident R1 gets up and wandered the smoking area. At 8:45 p.m. Resident R1 re-entered the facility. At 8:46 p.m. Resident R1 walks to ambulance exit and goes through the ambulance exit area. At 8:47 p.m. Resident R1 was observed via security footage in the parking lot leaving the area. At 8:52 p.m. Resident R1 left the facility campus. During an interview on 10/10/23, at 10:20 a.m. Maintenance Supervisor Employee E1 stated: the alarm would go off to the ambulance door exit only if Resident R1 was wearing a wander guard. The alarm on 9/30/23 did go off. Security Guard Employee E7 was the security guard that evening and did not respond to the alarm. Security Guard Employee E7 reset the alarm at 8:46 p.m. and he did not recheck the cameras. The alarm can be reset at the security station. During an interview on 10/10/23, at 10:39 a.m. Security Chief Officer Employee E2 stated: we had two security officers working on 9/30/23. Security Guard Employee E7 and Security Guard Employee E9. Security Guard Employee E9 was walking the floor at the time of the incident and Security Guard Employee E7 was at the security desk. During an interview on 10/10/23, at 11:32 a.m. Resident R1 stated that he cannot see as well as he used to out of his left eye. He has a place that is local. That is where he lived before, I got sick. Been here for 5 months and he is ready to get out of the nursing home. During an interview on 10/10/23, at 11:53 a.m. the Director of Nursing (DON) stated: Resident R1 returned on 10/1/23 at 4:33 a.m. We do not have statements from all the staff working the evening of 9/30/23. We completed accountability sheets. The sheets are done by nursing staff. Nursing staff coming on the shift and leaving the shift, do a head count of the residents and sign the sheets. This is a part of our corrective action. During a phone interview on 10/10/23, at 1:54 p.m. Nurse Aide (NA) Employee E4 stated: been working at the facility a couple of months. Resident R1 was not my resident that evening. I just know that a staff member said that Resident R1 was not there. That staff person went to the supervisor. I don' t recall name of the staff person; I think she was agency staff as well. No re-education was done with me. During a phone interview on 10/10/23, at 2:08 p.m. with Agency Registered Nurse (RN) Employee E5 stated: I came to the work, around 11:30 p.m. The supervisor gave me the keys for my assignment. As I went through my chart, someone was checking on people. We realized Resident R1 was missing. The aides said they did not see him. I called and told the supervisor he was not here. I went and started looking for him. I think the RN supervisor went to look for him. The aides also were looking for him. I cannot recall the time, the RN Supervisor said he was located, and his family brought him back. The RN Supervisor stated he thought he eloped. The family never called to say he was gone. The RN supervisor was (Proper name) something. Or another name. It was an aide that figured out he was missing. The resident is fully alert and oriented. He did not come with any medicine or paperwork. I was told he cut his wander guard off. I was just going down and the aide came and told me he was missing. The resident was fully dressed, like he was going to church, like a visitor. During a interview on 10/10/23, at 2:57 p.m. Registered Nurse (RN) Supervisor Employee E6 stated the following: I did not provide a statement to the Director of Nursing. On 9/30/23, in the middle of the night, a nurse aide that does the wander guard checks said Resident R1 was not here. Camera checks found Resident R1 left the facility around 8:45 p.m. I contacted the Director of Nursing and attempted to call Resident R1's family and was unsuccessful in doing so. We called the police, and they were able to locate Resident R1. I did assess Resident R1 upon his return. No issues found. I'm not familiar with this guy. The Nurse aide that found he was missing was Nurse Aide (NA) Employee E11. We task one individual to the tasks to check the wander guards. Nurse Aide (NA) Employee E 11 was tasked with other things that evening. And I was not provided re-education about elopement. On 10/10/23, at 3:01 p.m. Nurse Aide (NA) Employee E11 was called for her statement and did not answer. During a phone interview on 10/10/23, at 3:21 p.m. Security Guard Employee E7 stated the following: I was working with another senior guard. I was new. This individual that eloped saw the guard and figured there was no one at the front desk and walked out. When Resident R1 hit the door, I was under the assumption that if the door alarm was going off, it would lock. I did not recognize Resident R1 as a patient. Normal patients are in wheelchairs. I did not know this guy. Resident R1 looked quite normal, like a worker. Like someone going out the wrong door. When the chief told me someone eloped, then we looked at the tape. I was told I should have looked at the tape sooner. Since I was new, I did not. I just assumed someone walked by the door and thought someone would go to where they were assigned. I thought it was a false alarm and I shut off the alarm. It was a complete failure. There was a 6-hour difference between the time Resident R1 walked out and the time he left. We had a lot going on that night on 9/30/23. I thought the doors locked when the alarm goes off, and they do not. I should have done more. Security Guard Employee E7's personnel record indicated he started working at the facility on 9/12/23 and he was trained on emergency preparedness procedures and the routine tasks involved in his job description. On 10/10/23, at 4:13 p.m. Nurse Aide (NA) Employee E8 was called for her statement and did not answer. Nurse Aide (NA) Employee E8 personnel record indicated that her first start date at the facility was 6/25/23. Her record indicated that she received orientation on abuse and elopement procedures on 7/27/23. On 10/10/23, Immediate Jeopardy (IJ) was called and a template was provided to the facility at 2:24 p.m., and a corrective action plan was requested. On 10/10/23, at 7:20 p.m. an immediate action plan was received and accepted which included the following interventions: 1. Resident R1 was evaluated for injuries and none were found, Resident R1 was re-evaluated for safety, Resident R1 doctor was notified, 1-hour checks were put in place, his careplan was updated to include self-removal of wander guard, and a photo was placed at the front desk. 2. All residents were immediately re-evaluated using the elopement risk assessment to ensure wandering behaviors were identified, care plans updated, and ensure monitoring of wandering residents via Q1-hour safety checks completed 10/11/23 at 11:00 a.m. 3. Whole house audit of elopement risk assessments was completed by 10/11/23 at 11:00 a.m. 4. Updated care plans for residents with elopement risk, residents identified as elopement risk have a wander guard, security notified by 10/11/23. 5. Accountability checks forms completed at shift change every shift to ensure monitoring of all residents by 10/11/23, end of the 7 a.m. to 3 p.m. shift. 6. Residents identified as exhibiting wandering/elopement behavior will be identified on the 24-hour report by 10/11/23 at 11:00 a.m. 7. Residents identified as elopement risk will have wander guard placed and have Q1-hour checks for wandering residents for 72 hours by 10/11/23 at 11:00 a.m. 8. Nursing Staff Inservice beginning immediately on 10/10/23 and continuing at the start of each shift about elopement policy, accountability sheets, and Wander guard system. The training will be completed by 10/11/23, at 3:00 p.m. Nursing staff was identified via facility signature log to ensure full attendance. 9. Security staff was in-serviced the beginning of the shift about the elopement policy, exit-seeking behaviors, and the Wander guard system. All security staff completed the in-service by 10/11/23 at 3:00 p.m. Security staff was identified via facility signature log to ensure full attendance. 10. Quality Manager notified of the elopement and plan of correction on 10/10/23. Elopement policy reviewed and revised on 10/10/23. Review of updated Elopement policy on 10/11/23 during QAPI meeting. 11. The ADON/designee will monitor daily the accountability sheets daily for 4-weeks starting 10/10/23; weekly for 4-weeks, bi-weekly for 4-weeks, then monthly for 4-weeks. On 10/11/23, at 7:42 a m. the facility provided an updated Elopement policy. On 10/11/23, at 9:00 a.m. facility QAPI meeting took place and included the review of the new Elopement policy. During observations on 10/11/23 starting at 10:00 a.m. each nursing units (Nursing units 2A, 2B, 3B, 4A, and 4B) were found with a binder containing accountability sheets used to verify resident whereabouts. On 10/11/23, at 11:32 a m. the facility provided a report used for auditing elopement assessments. The Report indicated all residents were re-assessed for elopement risk. During observations on 10/11/23, at 11:44 a.m. Security binder with wandering risk residents was observed. Review of 12 resident clinical records on 10/11/23 indicated that the facility staff completed elopement assessments, updated care plans, and put accountability sheets in place. During interviews on 10/11/23, from 12:58 p.m. through 1:39 p.m. 16 employees confirmed they had received education on the new facility elopement policy and procedures, exit-seeking behaviors and interventions, and use of the Accountability sheets. On 10/11/23, at 1:47 p.m. the Director of Nursing provided audit documentation verifying appropriate use of Accountability sheets. Verification of the facility's Corrective Action Plan revealed all elements of plan were substantially completed and the Immediate Jeopardy was lifted on 10/11/23, at 2:32 p.m. During an interview on 10/11/23, at 3:02 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide adequate supervision resulting in an elopement for Resident R1. This failure created an immediate jeopardy situation for one of 195 residents. 28 Pa. Code 201.18 (e)(1)(3) Management. 28 Pa. Code 207.2(a)Administrators Responsibility 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services.