**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, select facility policies, and information submitted by the facility and staff interviews, it was determined that the facility failed to provide adequate staff supervision of a resident to monitor the resident's whereabouts and timely identify the resident's absence from the facility to assure prompt implementation of established procedures for a missing resident, which placed the resident in immediate jeopardy to her health and safety for one resident out of 12 residents sampled (Resident 18). Findings include: A review of the facility policy dated February 2017 entitled Wandering/Elopement revealed that It is the policy of the facility to ensure the safety and welfare of its residents, including those who are cognitively impaired or mental disturbed and are at risk for leaving the facility without regards to their own safety. According to the policy, on admission all residents will have their pictures taken for immediate positive identification in case of elopement and for positive identification for medication and treatment administration. On admission, readmission, quarterly, the elopement risk assessment will be completed on all residents. When a resident, who is identified as at risk to leave the facility unattended, cannot be located on the unit or any resident identified as missing from the facility, the following procedure will be followed: charge nurse will notify the unit manager or nursing supervisor on duty, on 3-11, 11-7, weekends and holidays, the nursing supervisor will initiate internal notifications, including security, administrator or designee to coordinate search efforts. The facility policy also indicated that if the time frame for this external and internal search exceeds 45 minutes and is unsuccessful, administration will report the incident to the police department with a complete description of the resident and what he/she was wearing (if known). The resident's family and/or responsible party will also be contacted, as well as the attending physician. A review of the clinical record revealed that Resident 18 was admitted to the facility on [DATE]. The resident's diagnoses included urinary tract infection, diabetes, and enterocolitis due to clostridium difficile (bacterial infection that causes diarrhea and inflammation of the colon). Review of Resident 18's Pre-admission Screening completed by the facility on June 22, 2023, indicated that the resident required supervision with dressing of her upper extremities, required minimal staff assistance for lower extremity dressing and toileting. According to the screening, the resident's functional status as of June 22, 2023, indicated that the resident used a rollator walker for ambulation with minimal assistance of staff, and transferred with minimal assistance of staff. A review of Resident 18's Elopement Risk Evaluation dated June 23, 2023, indicated that the resident was not identified as an elopement risk. Social Service progress note dated June 26, 2023, indicated that Resident 18 was cognitively intact. Social Service progress noted dated June 28, 2023, indicated that Resident 18 requested discharge on Monday, July 3, 2023. According to the note, the resident requested discharge prior to the holiday so if there was any delay in her home health therapy, at least family would know her needs. The resident's family was to come in the facility for therapy to provide family training prior to discharge. Additionally, the resident declined to have her picture taken for her electronic medical record at that time. A review of information dated July 1, 2023, submitted by the facility revealed that Resident 18 was last seen in the facility by nursing staff at 8:51 a.m. on that date when she was provided morning care and medications. According to the initial facility report, at 12 noon, on July 1, 2023, Employee 3, registered nurse, identified that Resident 18 was no longer in the facility. Employee 3 called the resident's family which revealed that the resident's daughter who had been in earlier that morning, had taken the resident home. However, this account of the resident's absence was not accurate and it was later determined that Employee 3, RN did not identify the resident as missing from the facility until approximately 2 PM on July 1, 2023. Review of witness statement provided by Employee 1, nurse aide, dated July 1, 2023, revealed that from 8:30 a.m. until 9:00 a.m. she observed Resident 18 in the bathroom washing up at the sink. Employee 1 stated that she saw two visitors in the resident's room at 9:15 a.m. When Employee 1 went to perform vital signs on Resident 18 at 10:30 a.m., the resident was not in her room, and she reported it to the supervisor (Employee 3, registered nurse) and the resident's assigned nurse (Employee 2, licensed practical nurse). When Employee 1 delivered Resident 18's lunch tray at midday, the resident still wasn't in her room, and Employee 1 again reported to Employees 3, RN and Employee 2 that the resident was not in her room. Review of witness statement provided by Employee 2, licensed practical nurse, dated July 1, 2023, revealed that at 8:50 a.m., Resident 18 was administered her morning medications and was in the bathroom getting ready for the day. At 11:00 a.m. Employee 2 went into the resident's room to administer medication {perform blood sugar check}, but resident was not in her room. Employee 2 stated that she thought the resident was doing therapy. At 11:30 a.m. the resident still was not in her room. At 12:00 p.m. she thought Resident 18 was on the patio with family or in a visitation but forgot to sign out. Employee 2 searched the lounge, but the resident wasn't there. At 2:00 p.m. Resident 81 still was not in her room. Employee 2 stated that she went to look for the resident in the lounge, in the patio, and outside of the building, but was not successful in locating the resident. At that time, Employee 3 called the resident's family and realized the patient had been discharged without any knowledge of any nursing staff. Review of witness statement provided by Employee 3, registered nurse, dated July 1, 2023, revealed that Resident 18 was last seen at 8:51 a.m. in her bathroom washing up. At 9:30 a.m. Resident 18 was not in her room, television was on, and belongings were on overbed table, assumed resident was with therapy. At 10:30 a.m., the resident was not in her room. At 11:45 a.m. when staff delivered lunch tray, the resident was not in her room and the staff checked the dayroom. The resident was not in the dayroom and Employee 3 assumed she was on the patio with family. At 2:15 p.m. Resident 18 still was not in her room. The dayroom was checked again, the patio was checked, the floor perimeter was checked, and the sign-out book and chart were checked to see if resident had signed out. Employee 3 then called Resident 18's emergency contact number 2/ resident representative (daughter) who stated that she hadn't spoken to the resident in two days. At 2:30 p.m. Employee 3 called the resident's emergency contact number 2 (daughter) who stated that her mom is home. According to this daughter, the resident had called her and stated she wanted to go home, and she came and got her. At that time, the resident's physician, the Nursing Home Administrator, and Social Service were made aware that the resident had been missing from the facility and was home with family. The facility's report further noted that the resident and family were instructed to return to the facility for proper discharge instructions, education, and prescriptions. According to the report, the resident and family refused to return to the facility. The facility then considered the resident to have discharged against medical advice. The facility determined that the resident discharge appeared to be safe for a competent resident, but against medical advice. Interview conducted with Employee 1, nurse aide, on July 6, 2023, at 9:00 a.m. confirmed that she twice reported to both the nursing supervisor and the resident's assigned nurse that Resident 18 was not present in her room during observations at 10:30 a.m. and at time of lunch tray delivery, approximately 11:45 a.m. Interview was unable to be conducted with Employee 2, LPN. The surveyor called Employee 2 on July 6, 2023, at 10:30 a.m., left a message with no return call received. Interview conducted with Employee 3, RN, on July 6, 2023, at approximately 11:30 a.m. confirmed that she did not initiate a timely search when Resident 18 was identified as missing from the nursing unit and failed to timely notify facility administration and security that the resident was missing. Employee 3 confirmed that she failed to promptly implement the facility's established procedures for a potential missing resident. The facility's conclusion was that the resident who was scheduled for discharge on [DATE], had called her daughter on July 1, 2023, to come and get her. The resident's daughter proceeded to take the resident home without checking with facility nursing staff. The resident was missing from the facility for approximately 5 hours and 30 minutes according to the documentation that was provided at the time of the survey and interviews with staff. Licensed nursing staff were unaware that the resident had left the building until they called the resident's daughter at 2:30 p.m. Staff failed to monitor the resident's whereabouts when staff had not seen the resident in facility after 8:50 a.m. on July 1, 2023. The facility relied on its sign-in/sign-out log to determine when residents leave the nursing unit which was ineffective in preventing Resident 18 from leaving the facility without staff knowledge. Employee 3, RN and Employee 2, LPN failed to timely act on Employee 1's reports that Resident 18's absence from her room and failed to promptly implement procedures to locate a missing resident and to ensure Resident 1's safety. As a result of the failure to adequately supervise a resident's whereabouts and licensed nursing staff's failure to promptly implement procedures for a potential missing resident in response to reports that the resident was not present in the facility, Immediate Jeopardy to the health and safety of residents was identified. The Nursing Home Administrator was notified of the immediate jeopardy and provided the IJ Template on July 6, 2023, at 1:45 p.m. The facility's immediate action plan provided to the survey team at 2:38 PM on July 6, 2023, was as follows: 1. Audit for Profile picture of every resident in-house to be in EMR 2. Audit all residents have had an elopement risk assessment completed 3. Verbal and Written education to all resident on signing out at the nurse's station prior to leaving the floor or the facility. 4. Facility will call all resident family/representative to inform/educate them of the requirement to sign a resident out prior to taking them off the floor or out of the facility for any reason. 5. Education of nursing staff on the timely implementation of procedures for a missing resident. 6. Audit that all residents are present and accounted for. During the onsite visit to the facility on July 8, 2023, verification of the implementation of the facility's removal plan was completed and the Immediate Jeopardy was lifted on July 7, 2023, at 8:30 a.m. 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