**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide adequate supervision during a planned out-of-facility activities outing to a theater, for one of six residents reviewed who were at risk for elopement. This resulted in Resident R138 exiting the theater and was unable to be located for one hour and 45 minutes. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R138) Findings include: Review of facility policy, Policies and Procedures Related to Wandering and Elopement dated May 20, 2014, revealed that the purpose of the policy is to assess residents for the purpose of assuring their safety and determine the risk for wandering and/or elopement within or out of the home. Continued review revealed that all staff must maintain a heightened awareness of their surroundings, the residents in our care, and environmental issues that might lead to a resident's elopement. Review of Resident R138's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated July 30, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 11, which indicated that the resident was moderately cognitively impaired and that he had behaviors of inattentiveness. Further review revealed that the resident was able to walk independently without an assistive device. Review of Resident R138's Elopement Evaluation, dated July 29, 2024, revealed that the resident was identified by the facility as being at risk for elopement, related to ambulation status, cognitive impairment and history of exit seeking behaviors. The evaluation noted that an elopement care plan was initiated. Review of Resident R138's care plan, dated initiated March 8, 2023, revealed that the resident was at risk for elopement and has exhibited exit seeking behaviors. Interventions included to encourage the resident to look for a staff member if he feels lost, confused or needs assistance, to redirect and reorient the resident as needed, and to maintain safety. Continued review of Resident R138's care plan, dated initiated July 26, 2024, revealed that the resident had memory deficits, requiring reminders and invitations for consistent activity participation. Interventions included that the resident will be invited to community outings to enhance life enrichment. Review of progress notes for Resident R138 revealed a nurses note, dated August 25, 2024, at 3:33 p.m. which indicated that the resident went on an out-of-facility activities outing to a theater. The note continued that, At 3pm staff notified security desk resident had eloped and police were called. Police arrived at 3:15 p.m. and began searching the area for the resident. Continued review of progress notes for Resident R138 revealed a nurses note, dated August 25, 2024, at 4:15 p.m. that nursing staff confirmed that the resident was located. Further review of progress notes for Resident R138 revealed a nurses note, dated August 25, 2024, at 5:10 p.m. that the resident returned to the facility. The resident was noted to be at his baseline and was placed on every fifteen-minute checks. Review of facility documentation reported to the Pennsylvania Department of Health on August 26, 2024, at 4:09 p.m. revealed that Resident R138 was on an out-of-facility activities outing to a theater on August 25, 2024, and that at 2:15 p.m. it was discovered that the resident was unable to be located. The resident was located at 4:00 p.m. at a river toll bridge commission building and subsequently returned to the facility. Review of Google Maps revealed that the river toll bridge commission building was 0.2 miles, approximately a four minute walk, from the theater, in a busy [NAME] area along a waterfront. Interview on October 17, 2024, at 1:27 p.m. Employee E10, activities aide, stated that on the day of the planned activities outing to the theater, two residents cancelled, so Resident R138 was added to the trip roster the morning of the outing. Employee E10, activities aide, stated that six residents were accompanied to the theater by one other activities aide and himself. Employee E10, activities aide, stated that Resident R138 was seated by his coworker and that he periodically checked on all of the residents during the theater performance. Near the end of the first act, Employee E10, activities aide, stated that he noticed that Resident R138 was not in his seat and that he got up and checked the area for the resident as well as asked theater staff if they had seen the resident. Employee E10, activities aide, immediately initiated elopement protocol and notified the local police. Employee E10, activities aide, stated that additional facility staff arrived to assist with the search and that the police received a call from the river toll bridge commission building with a description matching Resident R138. Facility staff went to identify the resident and brought him back to the facility. Employee E10, activities aide, stated that prior to the elopement incident with Resident R138, that the facility did not have an official protocol in place for screening residents signed up for out-of-facility events to identify their care needs, such as for elopement risk identification. Review of facility documentation revealed a witness statement, dated August 25, 2024, from Employee E11, activities aide. Employee E11, activities aide, noted that Employee E10, activities aide, asked her where Resident R138 was and that she did not see the resident. Continued review of facility documentation revealed another witness statement, dated August 27, 2024, from Employee E11, activities aide. The employee indicated that two residents were seated completely behind both her and the other activities aide and that she periodically checked on the residents. Employee E11, activities aide, indicated that she did not know which residents on the outing were elopement risks. Review of facility documentation, Elopement Preparedness and Response, dated September 3, 2024, revealed that the facility determined that the root cause of Resident R138's elopement was due to the seating arrangement at the theater. Resident R138 was seated out of sight of staff and therefore staff were unable to supervise and redirect the resident to remain in a safe location throughout the outing. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to provide adequate supervision of a resident who was identified as an elopement risk by the facility. Resident R138 was unable to be located during an out-of-facility activities outing to a theater on August 25, 2024, from 2:15 p.m. until he was found at a river toll bridge commission building at 4:00 p.m. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) on October 17, 2024, at 1:58 p.m. On August 25, 2024, the facility initiated a plan of correction to address the failure of ensuring that a resident was adequately supervised to prevent elopement. The facility plan of correction included the following: 1. [Resident R138[ was assessed on August 25, 2024, at 5:10 p.m. A full assessment was completed of [Resident R138[ by Registered Nurse Supervisor. No adverse effects or injuries noted. Increased supervision initiated with 15-minute checks upon return to the building and continued through August 29, 2024.[ Resident R138[ placed on purposeful rounding every hour as of August 29, 2024, and rounds continue. 2. All residents with wander guards [device that is placed on resident's wrist or ankle which sound alarms or prevent doors to be open for exit] were verified to ensure electronic wander guards in place and functioning. Audit completed by Registered Nurse Supervisor including verification of orders, placement and function of wander guard; review of care plans updated and noted in clinical record. Wander guard master list updated, reviewed and provided to Interdisciplinary team on August 26, 2024. 3. Facility off premise policy was created August 30, 2024, pertaining to off premises activities. New procedure developed to include staff education and evaluation of residents prior to attending an outing to ensure each resident's appropriate supervision and needs are met to include review of elopement risk, mobility needs, hygiene, toileting, meal and hydration intake, as well as other ADL [activities of daily living] needs related to staffing and/or volunteer support. Activity trip form is reviewed and approved by activities supervisor and clinical service manager for all residents prior to attending an outside activity; any deviations from the roster are reviewed by activities supervisor prior to leaving the premises. Nursing and security staff are updated regarding residents who are participating in event off premises. Resident profile binder in place with instruction for every off premises outing which is provided to staff prior to leaving for the activity that includes elopement risk, safety needs and medical needs. During the off premises outing all residents will be required to stay within the facility group under the supervision of a responsible party as per policy. 4. Activities staff involved in the incident received immediate education on escorting residents to outside activities and the requirement that residents will not be left unattended at any time. All activities staff education completed on August 28, 2024, on outings protocol. No additional off-site activities were held from August 25, 2024, through August 27, 2024. 5. On August 27, 2024, facility activity form updated to reflect a review by nursing and activities to ensure sufficient staff and supplies are available for the outings including a review of elopement risk, dietary needs, personal care needs and medical needs. Audits of forms completed with final review by activities supervisor and clinical service manager. All outings forms will continue to be reviewed and approved by activities supervisor and clinical service manager prior to any outings. 6. QAPI [Quality Assurance Performance Improvement] meeting held September 27, 2024, and education, audits and policy reviewed by IDT [Interdisciplinary Team]. Next QAPI meeting scheduled for October 25, 2024. A review was conducted of staff education, wander guard and activity forms audits and off-premise activities policy that was created related to Resident R138's elopement. Interviews with facility staff were conducted on October 17, 2024. Facility staff provided extensive feedback and understanding of the facility's new off-premise policy and process. Facility staff verbalized that all residents and staff assignments are reviewed prior to all outings to ensure that supervision and resident care needs can be met. All residents who have been identified as at risk for elopement receive one-to-one supervision during outings. All residents who attend the outing have information, including their supervision and care needs, in a binder that is taken along on the outing. Facility staff verbalized that all residents are assigned to specific staff during all outings and that no residents are ever left alone. Facility audits were reviewed and residents who were identified by the facility as being at risk for elopement had appropriate elopement prevention measures in place. Facility activity forms were reviewed and indicated that all residents and staff were reviewed for appropriateness and care needs prior to all out-of-facility activities. Review of facility documentation revealed that the corrective action plan was immediately initiated on August 25, 2024. The facility's action plan was accepted on October 17, 2024, at 4:48 p.m. and identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services