**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and person-centered care plan interventions that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for two residents. This failure created an immediate jeopardy situation for two of 21 residents who were identified as at risk for elopement (Residents R6, and R111). Findings include: Review of the policy Accident Prevention dated 1/2/25, indicated the facility policy is to prevent resident accidents and injuries to the extent possible by maintaining, as much as possible, an environment free from accident hazards and by assuring residents receive adequate supervision and assistive devices to prevent accidents. Review of the policy Wanderguard and Elopement dated 1/2/25, indicated the facility implements safety measures for residents who wander and/or are at risk for elopement to attempt to prevent elopement. Nursing evaluates resident upon admission and when the resident exhibits an exit seeking behavior in the Electronic Health Record (EHR) - Elopement Observation. Implements person-centered interventions to attempt to prevent elopement. Review of the admission record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/15/25, indicated the diagnoses of metabolic encephalopathy (a brain disorder caused by metabolic disturbances in the body, leading to impaired brain function), repeated falls, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Section C0500 indicated a Brief Interview for Mental Status (BIMS - a screening test that aides in detecting cognitive impairment) score of 12 - moderately impaired cognition. Review of Resident R6's Elopement Observation dated 10/24/24, indicated no elopement risk factors identified or verbalized. Review of Resident R6's Elopement Observation dated 10/30/24, indicated new admission who has made statements questioning the need to be here checked yes. Does the resident exhibit any additional elopement risk criteria? - Other -wanting to go outside was checked as yes. Elopement care plan initiated. Review of Resident R6's care plan dated 10/30/24, indicated behavioral symptoms - apply wanderguard (a bracelet that alerts staff if a resident has gone through an alarmed doorway to the outside of the facility) to resident. Check placement of wanderguard every shift. If not on resident, then replace as soon as possible. Check function every night. Review of Resident R6's care plan intervention dated 10/31/24, indicated resident needs supervision to go outside to the courtyard. Review of Resident R6's progress notes indicated 31 occasions of incidents of confusion, resisting care, agitation, self-propelling up and down hallways, being found on the basement level of the facility, seven falling episodes and ultimate elopement from 3West Unit on 3/14/25, as follows: -10/24/24, at 3:00 p.m. indicated resident is alert and oriented at baseline but brother states resident is having some short-term memory issues related to recent urinary tract infections. Resident had fallen at his personal care home and hurt his wrist. Resident enjoys being outside and sitting in the sun. Resident's brother states resident has been doing this for years. -10/25/24, at 2:02 p.m. care conference indicated resident requires this level of care as lesser levels of care were unsuccessful. -10/25/24, at 10:18 p.m. indicated resident transfers with assist of one and self-propels in wheelchair independently. -10/26/24, at 2:43 p.m. Indicated resident is alert, verbal, confused at times. Self-propels in wheelchair around room and unit. -10/27/24, 6:39 a.m. indicated resident gets in and out of bed unassisted and sits in wheelchair. Somewhat confused. -10/27/24, 2:24 p.m. indicated resident alert, verbal, confused at times. -10/28/24, 2:20 p.m. indicated resident presented as alert and oriented times three, with periods of forgetfulness. Resident has short term memory loss and is very social. -10/30/24, at 3:14 p.m. indicated resident verbalized wanting to go outside. Courtyard assessment completed and found resident to be unsafe to do so without supervision. Resident's cognition fluctuates. His confusion increases at different times of the day as well as when resident has a medical issue occurring. Resident's brother reported resident would stay outside for hours on end in extreme heat and not drink or use the restroom which had resulted in multiple infections and episodes of dehydration prior to placement. Resident does lack safety awareness. Residents gets irritated at times when resident is reminded of safety issues including going outside and verbalizing to staff, resident would go regardless of supervised request. A wander guard has also been ordered. -11/6/24, 12:34 p.m. indicated resident was refusing grip socks. Resident's brother indicated resident is impulsive and implored resident that it's easier to call for help to the chair than help off of the floor. Resident is non-compliant. -11/7/24, at 5:29 a.m. resident found in wheelchair dressing himself. Resident indicated he is able to do for himself without help and refused for staff's assistance. After resident dressed, he self-propelled up and down the corridor. Resident is non-compliant. -11/7/24, at 12:47 p.m. indicated resident was seen by therapy, then within the hour was found to be walking around in the room, pants at his ankles and brief around his knees. Resident was very agitated. This has become regular practice that resident exhibits impulsiveness and sudden mood changes. -11/7/24, physician note indicated staff called earlier today because it seems like resident is having a little bit of an adjustment, where resident becomes quickly agitated with staff. Also seemed a little more confused than normal. The staff found resident urinating throughout his room, instead of in the bathroom where resident normally goes. -11/8/24, at 7:48 a.m. indicated resident alert to name only. Confused to time and place. Resident stated sometimes he does feel anxious, agitated, and depressed at times. Resident is often not asking staff for help when he needs help with transfers. Resident does have a history of encephalopathy. Staff noting that resident has periods of increased confusion as well as emotional lability. -11/20/24, physician note indicated staff noting that resident has periods of increased confusion as well as emotional lability. Resident said he likes to do outdoor activities and would previously kayak. IMPRESSION AND PLAN: 1. Normal pressure hydrocephalus (a rare condition that occurs when too much cerebrospinal fluid builds up in the brain) has caused chronic gait abnormality and imbalance. Mostly scoots around in the wheelchair. Also has led to some increased confusion and memory issues. Monitor closely. -12/15/24, at 2:25 a.m. indicated resident found on the floor. Registered Nurse (RN) in to initiate investigation. -12/17/24, at 12:11 p.m. indicated resident continues to transfer independently. -12/26/24, at 1:33 p.m. indicated resident continues to be non-compliant. -12/27/24, physician's note indicated resident incorrectly told me that when he fell, he went to the emergency room and had X-rays, but it was confirmed with the staff that this was simply not true. Resident does have baseline confusion. IMPRESSION AND PLAN: Fall. Again, this was 11 days ago. Resident did not complain of left arm pain initially to the staff. Staff does report that there are times they have discovered that resident has fallen and does not tell people. -1/26/25, at 10:59 a.m. resident with increasing agitation. Staff found stool on the floor and on resident and offered to help clean resident, but resident refused. -1/26/25, at 1:17 p.m. indicated while Nurse Aide (NA) was delivering lunch tray into residents' room, resident was seen in bathroom on the floor, in a sitting position underneath the sink. Resident explained he placed himself on the floor to do plumbing. Water was slowly coming out of the pipes underneath the sink. -2/8/25, 12:33 p.m. indicated resident was found sitting on floor in front of toilet in his bathroom. -2/9/25, at 6:03 a.m. indicated resident observed sitting on the edge of low bed at approximately 4:45 a.m. Assisted into wheelchair per resident request. Resident easily agitated with staff intervention. Remains moderate fall risk with impaired safety awareness. -2/17/25, at 4:15 a.m. physician note indicated a note in the communication book said resident has had some confusion. The resident does admit that he had some confusion last week and starting maybe ten days ago. Resident had a urinary tract infection. -2/19/25, at 6:31 a.m. indicated resident with increased confusion this, and prior shift. Hard time accepting help. Attempting to exercise in the bathroom and refusing to let staff help transfer to wheelchair. -2/19/25, at 11:50 a.m. indicated NA reported resident refused care this morning. Refused to go to orthopedic appointment and refused again to be cleaned up by NA. -2/20/25, physician's note indicated staff reported resident is having increased pain and noted to be more confused. -3/10/25, at 8:12 p.m. indicated resident was moving around the facility at approximately 7:00-7:15 pm. Resident was seen on the first floor (basement) by NA Employee E15, who notified the supervisor. But then resident's nurse Licensed Practical Nurse (LPN) Employee E16 came by, re-oriented resident and took resident back to his unit. Resident was placed safely in resident's room. Wanderguard is on the left wrist. Resident will be monitored every hour until midnight. When supervisor asked resident why he was on the first floor, resident said he wanted to see the sunset. -3/11/25, at 10:20 p.m. indicated resident self-propels throughout facility. Every one-hour checks maintained. -3/12/25, at 4:37 p.m. indicated staff notified that resident can't leave unit without supervision. -3/14/25, at 7:53 p.m. indicated spoke with resident's brother regarding resident wanting to go outside and safety concerns. Resident has wanderguard and needs to be supervised when outside in the courtyard. Resident on every two-hour safety checks due to recent increase in leaving the unit and trying to go outside. Resident's brother explained that resident loves to be outside and will spend most of his time out there if he can. Resident's brother said that he would try to come visit as often as possible to take him outside. -3/14/25, at 9:57 p.m. indicated around 3:45 p.m. NA reported that Resident R6 had eloped to the second floor and that she brought him up in his wheelchair. Review of the clinical record failed to include an Elopement Observation on 3/10/25, when Resident R6 was found in the basement unsupervised. Review of Resident R6's care plan failed to include an update or revision after resident was found in the basement unsupervised on 3/10/25. Review of a submitted facility document dated 3/14/25, at 3:30 p.m. indicated Resident R6's whose orders for level of supervision indicated may not leave third floor without supervision, was found on the second floor of the facility. Resident was seen on closed caption television getting on the elevator alone at 3:29 p.m. Resident attempted to go into the courtyard and was unsuccessful because the wanderguard alarmed. Resident is not permitted in the courtyard unsupervised. At 12:30 p.m. resident heads towards security (who turned the wanderguard alarm off). At 3:33 p.m. resident was observed in the second-floor activity room where activities were doing an activity. Interview on 4/7/25, at 9:50 a.m. Unit Clerk Employee E17 indicated some residents have wanderguards, night shift checks placement and function. When asked if there was a book with high-risk residents who wander on the unit, she replied no. Security has one on the second floor at the facility's entrance. Interview on 4/7/25, at 9:55 a.m. LPN Employee E18 indicated the wanderguard alarm goes off to the outside doors. The wanderguard doesn't stop residents from getting on and using the elevator. Interview on 4/7/25, at 10:00 a.m. Registered Nurse (RN) Employee E6 indicated in the evenings and overnight they have the elevators set so you cannot go to the basement. Staff cannot go from second floor or third floor to the basement on the evening or night shifts. Staff use the stairs. When asked who is in charge of the wander management program, RN Employee E6 indicated she believed it was Security or Administration, and that there was a list of wanderguards but no photographs. There's also a graph in the back of the DEA (narcotic book) book, which she went into the locked medication room to retrieve and brought back to the nursing desk area. Interview on 4/7/25, at 10:15 a.m. NA Employee E19 indicated we try to keep an eye on the ones that wander around. Interview on 4/7/25, at 12:53 p.m. LPN Employee E16 indicated on 3/10/25, she recalled coming back from dinner, and saw Resident R6 on the basement level of the facility where the employee cafeteria is located. LPN Employee E16 indicated she saw Resident R6 with NA Employee E15 who indicated Resident R6's trying to leave. LPN Employee E16 said to Resident R6 You know you're not supposed to be down here. Resident R6 responded with a laugh. Interview on 4/8/25, at 11:00 a.m. with NA Employee E19 indicated she recalled working 3/14/25, when Resident R6 got off the 3rd floor, stated NA Employee E20 was pushing Resident R6 back to the unit as she was coming out of the shower room with the shower bed and another resident. Interview on 4/8/25, at 11:08 a.m. LPN Employee E21 indicated Resident R6 likes to go down to the snack shop in the basement. Interview on 4/8/25, at 12:30 p.m. Unit Clerk Employee E17 pulled a binder out from the nursing desk on 3 [NAME] that had a wander list dated 10/31/24, and was unsure how often it should be updated. When asked how agency staff would know who was at risk for elopement, she indicated the staff would tell them who to watch. Interview on 4/8/25, at 2:30 p.m. NA Employee E22 indicated Resident R6's allowed to second floor but not outside by himself. Resident R6 goes to the vending machine in the basement, and he'll come back up. Interview on 4/8/25, at 10:30 a.m. Security Guard (SG) Employee E23 at the front lobby entrance, indicated security has a book of photographs. When asked if it was available for review SG Employee E23 indicated sure, I'll go get it. It's locked in the security office down the hall. Review of the admission record indicated Resident R111 was admitted to the facility on [DATE]. Review of Resident R111's MDS dated [DATE], indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), muscle weakness, and need for assistance with personal care. Section C0500 indicated a BIMS score of six - severely impaired cognition. Review of Resident R111's Elopement Observation dated 9/25/24, indicated no elopement risk factors identified or verbalized. Elopement care plan not needed at this time. Review of Resident R111's care plan dated 9/26/24 (the next day), indicated to monitor safety status on an ongoing basis and intervene immediately if found in an unsafe environment, position, or etc. Apply wanderguard to resident. Review of Resident R111's progress notes indicated the following: -11/24/24, at 3:38 p.m. resident is disoriented today. Resident called her daughter to notify her that she was in downtown Pittsburgh. Resident indicated I've been calling my family to tell them I am in downtown Pittsburgh, and they keep telling me to take a nap. -11/25/24, 9:30 a.m. physician's note indicated resident's daughter was concerned that she visited yesterday at the facility and her mother seemed to be more confused than her baseline. Concerned because resident refuses care at times and thinks she may not be clean and have a urinary tract infection. Informed daughter that Dementia does slowly progress. -11/26/24, at 9:24 p.m. indicated resident observed by staff and other residents as being aggressive and yelling at roommate. Resident did state she was upset with roommate and was yelling at her but would not hurt her. When questioned resident indicated I'm sick of everyone coming into my room to bully me. -12/3/24, at 5:17 a.m. practitioner's note indicated resident has dementia and was seen last week by physician for increased confusion. Behavior is thought likely due to advancing dementia. Resident has had some more behaviors in the last few days as well. -12/15/24, at 1:27 p.m. indicated Medical Records Employee E24 found Resident R111 in the 2 [NAME] breakroom (this unit was closed at the time and without supervision of staff. Employee E24 happened upon Resident R111 only by the need for employee to use the restroom). Resident was easily redirected. Informed the staff on 2 East (Resident R111's unit that is not a locked unit) and suggested resident be checked on regularly. Will inform Administrative staff. -12/17/25, at 11:23 a.m. indicated nursing reports that resident Sundown's (a neurological phenomenon that causes increased confusion and restlessness in people with dementia typically starting in the late afternoon). Staff report that she can be nasty and difficult to redirect in the evenings. Review of the clinical record failed to include an Elopement Observation on 12/15/24, when Resident R111 was found in the closed 2 [NAME] unit's break room. Review of Resident R111's care plan failed to include an update or revision after documented increased confusion on 11/24/24, 11/25/25, 11/26/24, 12/3/24, and 12/17/25 showing concerns about mental status changes, sundowners and advancing Dementia prior to resident being found unsupervised on the closed 2 [NAME] unit's break room on 12/15/24. The care plan failed to be updated or revised after Resident R111 was found on the closed 2 [NAME] unit. The care plan did not reflect a resident centered approach until revisions on 4/9/25, nearly four months post event. Review of a submitted facility document dated 12/15/24, at 1:01 p.m. indicated Resident R111 was found in the staff breakroom on the closed and unsupervised 2 [NAME] unit. Resident wandered there from her unit of 2 East without staff's knowledge. Wander guard was in place; however, would not have alarmed unless Resident R111 wound have gotten to an exit door leading to the outside of the facility. Review of Medical Records Employee E24's witness statement dated 12/17/24, at 10:35 a.m. indicated, I witnessed a resident sitting in the 2 [NAME] bathroom area. I asked her if she was okay. She responded yes. After I used the bathroom, I asked again if she needed anything. I informed the nurse there was a resident sitting in the 2 [NAME] bathroom area. Review of facility provided timeline indicated the following on 12/15/24: (information on timeline was received post event from CCTV.) -12:56 p.m. Resident R111 walks past agency staff member on 2 East nursing station. -12:57 p.m. Resident R111 walks past security guard and dietary worker at the entrance of 2 East and proceeded to the 2 East dining hall. -12:58 p.m. Resident R111 exits dining hall and heads towards 2 West. -1:00 p.m. Resident R111 goes past orange cones on 2 [NAME] in front of nurses station toward the low hall and goes behind the nurses station entering the employee lounge. Interview on 4/9/25, at 9:44 a.m. the Director of Nursing confirmed that the facility failed to make certain each resident received adequate supervision and person-centered care plan interventions that resulted in an elopement for Residents R6 and R111. The Director of Nursing and the Nursing Home Administrator were made aware that an Immediate Jeopardy situation existed for residents on 4/9/25, at 11:05 a.m. and an immediate action plan was requested. On 4/9/25, at 11:05 a.m. the Immediate Jeopardy template was provided to the facility administration. On 4/9/25, at 3:44 p.m. an acceptable Corrective Action Plan was received which included the following interventions: DON/Designee will immediately re-evaluate Resident R6 and Resident R111 for elopement risk on 4/9/25. DON/Designee will re-evaluate all residents for exit seeking behaviors by 4/9/25. Nursing staff/Designee will provide every one-hour safety checks on all residents for 24 hours. Residents who are at risk of elopement will have every one-hour safety checks ongoing to ensure resident safety. DON/Designee will provide appropriate supervision levels for all residents in their orders and person-centered care plans to include interventions such as resident specific activities such as 1:1 interactions, cards, outside to courtyard with supervision, etc. by 4/10/25. Review and update quarterly, annually or with any significant changes or with any event where elopement is an identified risk. DON/Designee will audit appropriate supervision levels for four weeks. DON/Designee will thoroughly investigate all incidents for root cause analysis and follow up with interventions. DON/Designee will audit all incidents for four weeks. DON/Designee will implement interventions for residents identified as an elopement risk to prevent residents from eloping on 4/10/25. DON/Designee will audit all interventions for four weeks. DON/Designee will update elopement assessments quarterly, annually or with any significant change or with any event where elopement is an identified risk. Security/Designee to take photographs of residents upon admission to the facility to ensure updated wander books, if they are at risk of elopement. Security providing all nursing units with wander books, with photographs and names/room numbers of residents by 4/10/25, and will be updated upon resident's admission and/or discharge. Policy for Wanderguard and elopement has been reviewed and facility will add addendum regarding supervision levels and also Security/Designee taking photos of residents upon admission to the facility to ensure resident at risk of elopement are placed in wander books are updated with names/room numbers on 4/10/25. Wander books to be updated upon resident admission/discharge and with room changes. Staff Educator/Designee will educate all staff on policies for Elopements, Assessments, Care Plan, Supervision, and Accidents by 4/10/25. Facility will review incidents at QI/QAPI quarterly. Immediate Jeopardy was lifted on 4/10/25, at 1:28 p.m. and the abatement plan was verified as follows: Both residents have been re-assessed, updated care plans, and physician orders for wandering with patient centered interventions added. 116 of 116 total residents were re-assessed, updated care plans, and physician orders for wandering with patient centered interventions as appropriate. 24 hours of every one-hour safety checks completed on all residents. Photo wander books located and verified 3 west, 3 east, 2 east, Security desk. 26 [NAME] staff are off and will receive education prior to the next shift worked. Total staff of facility is 108 the remaining 15 staff will be educated prior to the next shift worked. 55 agency staff have been trained and 93 regular staff have received education. 44 in person interviews verified education received 4/10/25, at 12:26 p.m. Addendum For [NAME] Ross Facility added to the policy and procedure for Wanderguard and Elopement for the [NAME] Community Living Centers. Next QAPI meeting will be held April 29, 2025. Exit interview on 4/11/25, at 2:30 p.m. information was disseminated to the Director of Nursing and Nursing Home Administrator that the facility failed to make certain each resident received adequate supervision and person-centered care plan interventions that resulted in an elopement for two residents. This failure created an immediate jeopardy situation for two of 21 residents who were identified as at risk for elopement (Residents R6, and R111). 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing Services.