**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on review of a South Dakota Department of Health (SD DOH) Required Healthcare Facility Event Reporting, record review, observation, interview, and policy review, the provider failed to provide a secure physical environment and adequate supervision to minimize the risk of an unwitnessed elopement by one of one sampled resident (22). Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on 2/28/24 at 9:36 a.m. to administrator A for F 689 Accidents related to physical environment and adequate supervision to prevent unwitnessed elopement: *On 2/21/24 at 4:24 p.m., the provider submitted a SD DOH Required Healthcare Facility Event Reporting, that reported resident 22 had left the building unwitnessed on 2/19/24 while staff were getting other residents into the dining room for the evening meal. Resident 22 was last seen by staff at 4:15 p.m. A visitor reported having seen a female with exact description of what resident is wearing .near the grocery store up town. At 5:20 p.m., a certified nursing assistant (CNA) located resident 22 near the school and brought her back. The provider's conclusion noted: -Resident will not keep wanderguard on. -Front door is locked and needs code/magnet to open door. -FRONT DOOR WAS NOT LOCKED PRIOR TO THIS ELOPEMENT AS RESIDENT WAS UTILIZING WANDERGUARD. WANDERGUARD BECAME INEFFECTIVE AS RESIDENT CUT IT OFF BETWEEN STAFF CHECK. *Review of resident 22's electronic medical record revealed two additional elopements occurred on 2/1/24 and 2/13/24. Her care plan was revised on 10/11/23 stated, Identify pattern of wandering. Intervene as appropriate. There were no specific interventions for the frequency of supervision. The care plan was not updated to address a change in the location of the WanderGuard bracelet from resident 22's left wrist to the left ankle. The only [NAME] intervention stated, WanderGuard bracelet left wrist. *Interview with director of nursing (DON) B revealed the only intervention change that was implemented since the incident on 2/19/24 was to keep the front door locked. However, observation on the afternoon of 2/27/24 and the morning of 2/28/24, and a further interview with DON B revealed the front door was not always locked. *Interview with buildings manager (BMgr) F revealed the exit doors at the end of the North and [NAME] resident hallways had door alarms when the doors were opened, but they did not have the magnetic lock system for WanderGuard bracelets. All of the other exit doors, including the front door, had the wander alert magnetic lock system but would only function when there was the presence of a WanderGuard bracelet. He checked the functioning of the door alarms weekly. He also checked the functioning of resident 22's WanderGuard bracelet when he accompanied resident 22 out the east service exit for smoke breaks. *The provider's undated Missing Resident/Elopement Policy had not been followed for the following: -Assessment: 1. A Wandering Risk Scale assessment is completed on admission, quarterly, and upon change of condition. The previous assessment completed for resident 22 was quarterly on 12/14/23. No assessment had been completed since her elopement on 2/19/24. -Prevention: 1. Interventions that may be used for residents identified as high risk for elopement include: a. Frequent monitoring of the resident's whereabouts to assure he or she remains in the facility (e.g., every one-half hour checks). -g. Environmental controls: The facility is secured to minimize the risk of elopement through: (a) functional alarm system, (b) safety locks or key-pad entry. - 4. Prevention strategies are listed on each resident's plan of care and reviewed .on at least a quarterly basis or with a change of condition. Resident 22's care plan did not specify a frequency for monitoring her location or any specific interventions or strategies. IMMEDIATE JEOPARDY REMOVAL PLAN On 2/28/24 at 12:46 p.m., administrator A provided the survey team with a written plan for the removal of the immediate jeopardy. The removal plan was approved by the survey team at 12:55 p.m. *Resident 22 has not left the facility unattended since 2/1/24. WanderGuard has been placed on left ankle. The nurse will confirm location of WanderGuard 4 [four] times a day. If the WanderGuard is not on person, WanderGuard will be found and placed on the person if [sic] unable to find then a new one will be put on the person immediately. Interventions have been updated and nursing will have to verify resident location in the facility every 2 [two] hours for 2 weeks and then every 4 hours for the entirety of Resident 22's stay at the facility. The care plan has been updated regarding the WanderGuard but does not specify location as the nurse is required to specify 4 times per day where the WanderGuard is located on Resident 22's body. The [NAME] intervention will not state the location of WanderGuard as above. *Specific interventions have been established to include nurse to verify where abouts [sic] of Resident 22 every 2 hours for 2 weeks than [sic] every 4 hours. WanderGuard placement will be verified by the nurse 4 times per day. The front door will remain locked at all times until resident 22 is no longer ambulatory or alternative placement has been established. Magnetic locks have been ordered for the [NAME] and North exit doors to ensure that Resident 22 cannot leave the facility unattended. Until magnetic locks are in operation of the [NAME] and North doors staff [sic] will respond to any and all alarms by going to the door, verifying if a resident is out of the facility while another staff completes resident head count to verify all residents are in the facility. The elopement policy will be followed if a resident leaves the facility. *Facility interventions will be 1. Weekly door alarm checks that are monitored by maintenance personnel or designee and documented, results will be reviewed monthly at QAPI [quality assurance performance improvement] for 6 [six] months then quarterly. 2. Elopement drills will be completed monthly by maintenance or designee to ensure staff know the process. The Elopements drills will alternate shifts to ensure that all staff have been through a drill. Education will be conducted after each drill to verify understanding and discuss things that could have gone better. Elopement drill results will be brought to QAPI by maintenance personnel or designee monthly for 6 months then quarterly. 3. Director of Nursing or designee will report education of staff, verification of resident and wander guard to QAPI Monthly for 6 months then quarterly. Director of Nursing or designee will perform audits to ensure wander guard is on Res [resident] 22 and that charge nurse if [sic] verifying location of resident weekly X4 [times 4] weeks, biweekly for 1 month, monthly for 6 months. All staff working 2/28/24 will be educated regarding elopement policy, Exit door alarm policy, new interventions of Resident 22 to keep her safe, and that the front door will remain locked at all times as above. All staff will be educated upon next shift worked by DON or administrator. All new staff will be educated during orientation by HR [human resources] personnel or designee. Agency staff will be educated by initialing the education provided in the Travel Agency Education Binder and verified by Director of Nursing or designee. *All audits , drills, and door alarm checks will be evaluated after 6 months by the QAPI committee to determine if audits will need to continue, cease or change in frequency. Administrator A also provided a copy of a quotation received on 2/28/24 for 2 units of a Dynalock Maglock system. Administrator A stated that was for installation on the north and west doors. On 2/28/24 at 2:30 p.m., the survey team determined the immediacy was removed. After removal of the immediacy, the severity and scope was a level D. 2. Observation and interview on 2/27/24 at 1:13 p.m. with resident 22 revealed she: *Walked about independently without assistive devices in the hallway from her room to the television lounge area outside of the dining room and then to the seating area in the lobby between the front entrance door and the nurse's desk. *Provided incomplete phrases and mixed thoughts when asked questions about how her day was going or about her interactions with staff and other residents. *Had a pleasant look on her face and periodically reacted to the surroundings with laughter and a partial statement. *Did not respond when asked what she had found funny. Review of resident 22's the electronic medical record (EMR) revealed: *A physician diagnosis dated 9/15/23 of unspecified dementia, unspecified severity, with anxiety. *A care plan focus was initiated on 10/11/23 for elopement risk/wanderer r/t [related to] cognition and mobility, with the interventions initiated on 10/11/23 to: -Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. -WANDER ALERT: left wrist. *The 12/9/23 quarterly Minimum Data Set (MDS) assessment coded her mental status was moderately impaired, wandering had occurred one to three days, and a wander/elopement alarm had been used daily. *A 12/13/23 Wandering Risk Scale assessment coded her as high risk to wander with a mental status as can follow instructions and communicate, a history of wandering, and had no reported episodes of wandering in the past 3 months. Review of resident 22's progress notes in the EMR revealed: *On 12/14/23, a Plan of Care Note stated she will state that she is leaving, when asked where she is going states 'to [NAME].' She goes out with the group to smoke at each smoke break. She spends much of the time in the lobby daily visiting with the other residents. Much of her conversation is very difficult to understand and often makes little sense. *On 12/16/23 at 10:34 a.m., a Behavior Note stated she had been wandering around and calling sister and brother over and over to pick her up. *On 12/21/23 at 12:09 p.m., a Health Status Note stated she was missing her wander guard. Device was found in her room. *On 12/31/23 at 4:01 p.m., a Behavior Note stated she wrote a note to 'boss man' about loving her two sons, the rest was unable to interpret. After she handed it to the nurse she headed straight to the door and held emergency exit and went outside. Staff followed her and convinced her to come back. She came back in tears. *On 12/31/23 at 10:38 p.m., an Incident Note stated she had been sitting up at the nurse's station visiting with other resident's [sic]. She said goodbye and headed down the hall towards her room. Moments later alarm went of [sic] at west hall emergency exit. Resident found walking across the parking lot towards the road. *On 1/1/24 at 2:56 p.m., a Behavior Note stated she walked out the front door, staff redirected her back in the facility. *On 1/1/24 at 6:40 p.m., a Behavior Note stated she left the table before being served. She starting walking fast toward the front exit. Nurse stopped her .She wanted to walk to her brothers house. *On 2/1/24 at 6:01 p.m., a late entry Alert Note stated Night nurse arriving to work and seen resident walking at the end of the parking lot. Nurse escorted her back to the facility. Wanderguard alarm did not sound when she had left. CNA found wanderguard alarm in her room. Unable to locate device in which resident had used to cut off. *On 2/5/24 at 5:39 p.m., a Behavior Note stated she attempted to leave out the front door and set alarm off. Staff redirected her. She said, 'I want to go out!' *On 2/13/24 at 3:30 p.m., a late entry Behavior Note stated she was seen exiting the building when family of another resident was leaving. AL [assisted living] resident hollered out that she walked out the door. No alarm sounded as res [resident] had cut off her wander guard again. Writer went out to get resident and walked with her to the end of the block and back. *On 2/19/24 at 5:07 p.m., an Alert Note stated staff were getting residents into dining room and noticed resident was not in her room. Residents [sic] neighbors [sic] daughter came to writer stating she seen a lady that looks like her moms [sic] neighbor with exact description of what resident is wearing near the grocery store up town. Writer sent CNA to go out and look for resident. *On 2/19/24 at 5:20 p.m., an Alert Note stated CNA located resident near the school and brought her back to WCC [[NAME] Care Center]. Resident stated, I was looking for my folks. Interview on 2/27/24 at 1:59 p.m. with social service designee (SSD) D revealed: *Resident 22 had walked out the front door with someone and that had happened a couple of times. *She cuts here WanderGuard off. *SSD D had been trying to figure out how to incorporate a chain so that resident 22 would not be able to cut the WanderGuard bracelet. *Resident 22 was usually looking for her brother and had some awareness of where he lives. It is pretty hard to get lost in [NAME] without someone noticing. *She had never tried to go out any other door than the front door. *Staff check placement and the presence of resident 22 frequently. We almost cannot let her out of sight. *The front door is locked now all the time. It was not locked before because we are not a locked facility. Interview on 2/27/24 at 2:20 p.m. with licensed practical nurse (LPN) I revealed: *She had worked for the provider full-time for about a year, and on and off for about 10 years. *When asked what an elopement risk factor for a resident would be, she replied that MDS coordinator C completed the elopement risk assessments. *When asked how she or others would know what interventions or assistance a resident needed, she stated that it was a small facility, we report together. *She further explained verbal reports were provided when staff members started their shift, that included ADL support and wandering risk. *When asked if there were certain residents as risk for unsafe wandering or elopement, she asked if she could look at my list of residents. She then reported there were seven residents with unsafe wandering and three of those resident's would go out of the building. When asked about the door alarms, she explained a wanderguard will alarm the back door. The front door will lock if a wanderguard is close to it and if the door is open it will alarm. The front door is always locked. *She explained that resident 22's Wanderguard was in place before the elopement, but she cut off her wanderguard. It was replaced and positioned in a different spot than the last location. *It was a busy time of the day. We investigated after being informed that she was seen downtown. *Every shift is checking placement of the wanderguard, and the doors are now locked. Interview on 2/27/24 at 2:38 p.m. with BMgr F revealed: *All of the exit doors have an alarm when the door was opened. *All of the doors, except the north and west resident hallway exit doors, have a mag lock that will alarm if a Wanderguard comes close to it. *When a door alarm goes off, the location would come up on the call light system at the nurse's desk. That included the front door. *The north door and west doors do not have mag lock on them, but they do have an alarm that would go off if the doors were opened. *The doors without a mag lock were locked from the outside. *He tested the functioning of the wander alert bracelets once a month. *Resident 22 must have walked out with some other people. *Cleaning staff have found resident 22's wander alert bracelets in various places. One of them was now completely missing. *He verified resident 22's bracelet was working and in place when she came close to the smoking exit door on the east service wing. Interview on 2/27/24 at 2:52 p.m. with CNA H revealed: *She was a traveling CNA and had only worked for the provider twice. *She would learn about the needs of residents during a report at the start of her shift and by looking in the computer. *Two residents would set-off an alarm when they were close to the door, including resident 22. *There was a code for entering the building by east service door and a different code for turning off a door alarm when a resident would set it off. Interview on 2/27/24 at 3:20 p.m. with LPN I revealed that the front door was locked at all times, the north door and the west door were not locked but would alarm if the doors were opened. Observation and interview on 2/27/24 at 5:30 p.m. when testing staff response to the alarm at the west exit door revealed: *CNA G responded in less than one minute after the alarm sounded when the west door was opened. *He reported that he had been in a resident's room at the other end of the west hallway. *He received an alert on the call light phone he carried with him while working. *LPN I then arrived. She explained she had come to check if someone had responded to the door alarm. Observation on 2/27/24 at 6:11 p.m. revealed: *Resident 22 was sitting on a bench in the lobby located between the front entrance door and the nurse's desk. *Two staff were sitting and conversing with each other at the nurse's desk. *A green light was displayed on the door locking system above the door. *Upon testing if the alarm would sound when the door was opened, the alarm did not go off. *The staff at the desk did not respond to the door that was being opened. *Resident 22 watched but did not move towards the door. Interview on 2/28/24 at 7:53 a.m. with DON B revealed: *Since resident 22's elopement on 2/19/24, the only different intervention was that they keep the front door locked. *When asked about the care plan regarding the frequency of monitoring her location, she responded, She is usually hanging around out here. She tends to watch for groups of people by the front door and attempts to go out with them. *The last time she went out she had been in isolation for COVID. *Staff check placement of wander alert bracelet once a day, and it was recorded on TAR [treatment administration record]. *Maintenance checks the functioning of the door alarms weekly. *The front door is unlocked now because of the door malfunction, but resident 22 cannot push the door open herself because it is too heavy. Review of the January and February 2024 TARs revealed WanderGuard for wandering check daily for flashing light, every shift left ankle had been documented every shift as completed. Interview on 2/28/24 8:06 a.m. with DON B revealed: *When the light on the door locking system above the front door was red it is locked and green is unlocked. *We usually lock them at 6:00 p.m. *When asked When are they unlocked and by whom? she responded, We lock them at night just for safety and referred to the crazy things that could go on in [NAME] at night. Review of the resident 22's care plan on 2/28/24 revealed the focus of elopement risk/wanderer r/t cognition and mobility had been revised with additional interventions: *Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: going out to smoke, calling her brother or sister, drinking coffee or capacino [sic] and going outside for a walk. *Monitor location every 2 hours for 2 weeks than [sic] every 4 hours while she resides in the facility. Document wandering behavior and attempted diversional interventions in behavior log. *Provide structured activities: toileting, walking inside and outside, reorientation strategies such as smoking, sitting in common areas, visiting with staff, activities. *The resident's triggers for wandering/eloping are not specific, she has random and frequent thoughts of wanting to go home or travel. The resident's behaviors is [sic] de-escalated by redirecting, telling her the weather is not suitable to leave right now, calling her brother and sister, going to activity or getting her a cup of coffee/capacino [sic]. *WANDER ALERT: wander guard will be worn at all times. If [resident 22] removes wander guard it will be immediately replaced. Review of the provider's undated policy, Exit Doors Alarm System, revealed: *Procedure: The alarm sounds each time a door that has been equipped with the system is opening, thus serving to notify staff that someone has made an exit. *Six doors have been equipped with alarms: - a. North outside exit door - b. [NAME] outside exit door - c. clinic door - d. east inside service door - e. front outside door - f. dining room emergency exit. *Presently, there are three different systems in use: - 1. North door, the [NAME] door, and the Clinic doors -- a. The alarm is controlled from the Nurse's station -- c. When one of these doors is opened, the buzzer at the Nurse's Station sounds and a light on the monitor indicates which door has been opened. - 2. On the East door and the Front door (faces South) -- a. The alarm is controlled from the computer at the Nurse's station. Alarms are connected to the Android pager system. --b. There is also an alarm that sounds at the door when the door is opened. --d. The East and Front doors are also equipped with the Accu-Tech Wander Guard system. --- i. This system is also connected to the Android pager system through the computer at the Nurse's station. --- ii. A notification will be sent to all staff Androids and an alarm will sound at the door when a resident equipped with a wander guard bracelet enters or exits. B. Based on observation, interview, record review, and policy review, the provider failed to investigate the correlation between meeting the needs of the resident and the timing of the fall incidents for one of two sampled residents (3) who were new admissions. Findings include: 1. Observation and interview on 2/27/24 at 3:10 p.m. with resident 3 revealed : *She was seated in a wheelchair in her room next to her bed and facing the window. *The room light was turned off and no music or television playing in her room. *The bed was at a lower level than the standard height. *The wheelchair had anti-roll back brakes over the back wheels. *She responded clearly to the questions asked. *She did not respond to how much assistance she needed to complete her activities of daily living (ADLs). Review of resident 3's the EMR revealed: *An admission diagnosis on 2/1/24 of dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. *A Plan of Care progress note on 2/1/24 at 4:03 p.m., the first one in resident 3's record, that stated she had been in the hospital and went to her son's home where she was having multiple falls. Son was working and unable to care for her during the day. *Physician orders started on 2/2/24 for: -Antiroll back bars to be placed on wheelchair. -Fall alarm to be placed on bed and wheelchair at all times. *The list of user-defined assessments completed since resident 3's admission: -Did not include a physical restraint assessment. -A Morse Fall Scale assessment was completed on 2/8/24 that noted a history of falling, impaired gait, and she overestimates or forgets limits. *The 2/8/24 admission MDS C coded: -Moderately impaired for her mental status. -Dependent on staff for toileting and substantial/maximal assistance to transfer. -Always incontinent of urine and occasionally incontinent of bowel. -Two or more falls since admission with no injuries. Review of resident 3's progress notes in the EMR revealed on: *2/1/24 at 7:00 p.m., resident sitting on her bottom on the floor in front of the bathroom. Resident was knocking on the door for help .new admit this day and is noted to be mildly confused reoriented to call light system .Writer cannot confirm understanding. *2/2/24 at 3:57 p.m., Found resident on the bathroom floor. *2/3/24 at 1:04 p.m., Refused personal cares this morning. She denies needing help with task. *2/3/24 at 9:57 p.m., Another resident came and got this writer .alarms are in place and going off .found sitting on her buttocks right inside her room door .resident states 'I fell.' *2/4/24 at 3:11 a.m., Does not use call light, has a pressure alarm in bed and in w/c [wheelchair]. *2/4/24 at 11:44 a.m., Reminded resident that she needs to call for help when standing or transferring, resident is upset with that. *2/5/24 at 11:44 a.m., Caught her self transferring herself to the toilet. *2/6/24 at 6:06 a.m., Sitting on the edge of the bed trying to get up several times since 0230 [2:30 a.m.], bed alarm has alerted staff to this. *2/8/24 at 2:38 a.m., Has covid [sic] and is in isolation for this .using video monitoring in her room at present, she is able to let staff know what she needs, toileting, a drink . *2/9/24 at 4:28 a.m. and 2/10/24 at 4:49 a.m., Is not able to make wants and needs known .Does not use call light for assistance. Check/[and] change Q2H [every two hours] and as needed. *2/11/24 at 1:03 a.m., Is able to make needs known .does not use call light. *2/12/24 at 12:52 a.m., awake and sitting on the edge of her bed so far tonight. *2/16/24 at 2:40 a.m. and 2/19/24 at 3:57 a.m., able to communicate her wants and needs .does not use call light. *2/20/24 at 9:52 p.m., Found her on the floor in the BR [bathroom]. Plan: Will try to keep resident in the lobby until staff can assist her with cares. *2/22/24 at 4:53 p.m., Fell on right side off bed onto floor mat. Bed low position. Fall in room. Bed alarm sounding. Review of the Fall incident investigations on 2/1/24, 2/2/24, 2/3/24, 2/4/24, 2/20/24, and 2/22/24 revealed: *All of the falls were unwitnessed. *None of the predisposing situation factors section documented the last time staff had contact with the resident and what wants or needs were addressed. Review of ADL documentation on the days for the falls noted above revealed only one-time entry was documented each day for the activities of Chair/Bed-to-Chair Transfer, Toilet Transfer, and Toilet Hygiene. Review of resident 3's care plan revealed: *A focus initiated on 2/27/24, The resident has had an actual fall with no injury. Poor communication/comprehension unknown origin. *The interventions for that focus included: bed/chair alarm, room close to nurses station, video monitor, bed in low position with fall matt on floor while resident in bed. *A focus initiated on 2/28/24, The resident is High, risk for falls r/t dementia. *The interventions for that focus included: -Anticipate and meet The [sic] resident's needs. -Be sure The [sic] resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Interview on 2/29/24 at 11:32 p.m. with MDS coordinator C regarding the intervention to anticipate and meet resident needs revealed he agreed the intervention should be more specific to address the potential risks related to falls. Interview on 2/29/24 at 1:32 p.m. with CNA/UMA J, who was also an unlicensed medication assistant and restorative therapy assistant, revealed: *The chair and bed alarms used for resident 3 were audible. *Resident 3 did not seem to even be aware it is sounding. *Usually [the chair alarm sounded] when she is attempting to use the bathroom. *She doesn't recognize the need for help. *The CNAs are supposed to document each time toileting occurs, but the first time someone documents, the button turns green. *CNA J knew there was another resident that the computer displayed the need to document every two hours, and that could be done for resident 3. Interview on 2/29/24 at 3:54 p.m. with DON B revealed: *The care plan to anticipate and meet the resident's needs was vague. *The documentation on the fall incident investigations did not correlate the provision of ADLs to meet the resident needs related to the timing of the falls. *The provider's fall policy did not address investigating that factor. *The provider's position changing monitors policy was not followed. Review of the provider's Fall Policy, updated on 12/17/20, revealed: *13. The Charge Nurse will review and update the Care Plan as needed. *14. The resident's fall will be discussed with the interdisciplinary team to gather information and implement necessary interventions to prevent falls. *15. The online PCC [point click care - a software program] incident report and investigation follow-up form will be reviewed and signed by the Administrator and Director of Nursing. *18. The nurse is to chart in PCC under RISK MANAGEMENT. -d. Factors: Check all that apply. Review of the provider's Position Changing Monitors Use Policy, updated on 7/3/20, revealed: *Policy: Position changing monitors are used to notify staff when a resident has exited his/her chair or bed. *Guidelines: A Positioning Changing Monitor is considered a physical restraint if/when the resident is afraid to move to avoid setting off the position changing audible alarm. *Procedure: -1. Resident will be assessed for falls risk. -2. When using audible position changing alarms a [sic] Physical Restraint Assessment will be completed. -Position changing monitor may be initiated by nurse --After completed falls assessment and physical restraint assessment (for audible alarms) show monitor to be an appropriate intervention AND --After care plan has been revised to include position changing monitor.