**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (CR #1) of 5 residents reviewed for quality of care. The facility failed to ensure CR #1, who was cognitively impaired and wearing a wander guard, received adequate supervision when the facility sent him to the doctor's office unsupervised. CR #1 left the doctor's office and was found outside of a building in the rain by a bystander. An immediate jeopardy (IJ) was identified on 1/26/24 at 9:40 a.m. While the IJ was removed on 1/27/24 at 3:30 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of elopement or injury. Findings include: Record review of CR #1's face sheet dated 12/2/23 revealed a [AGE] year-old male admitted on [DATE] and discharged on 12/1/23. His diagnoses were: metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition), need for assistance with personal care, difficulty in walking, lack of coordination, bacteremia (the presence of bacteria in your blood), diabetes, acute kidney failure, chronic kidney disease, hypertension (high blood pressure), and pain. Record review of CR #1's 5-day MDS assessment dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. He required assistance with ADLs. No wandering behaviors observed during the lookback period. Record review of CR #1's care plan last revised 11/30/23 revealed he required assistance with all ADLs related to: impaired cognition, impaired communication, impaired balance and weakness, start date 11/19/23. He had impaired communication as evidenced by reduced ability to be understood by others, reduced ability to understand others, and impaired daily decision-making ability, start date 11/19/23. Approach included to provide a quiet, non-hurried environment, free of background noises and distractions. CR #1 had impaired cognition which may increase as the disease progresses, start date 11/19/23. Approach included to offer reassurance when confusion increases. Record review of CR #1's Elopement Risk assessment dated [DATE] revealed the resident was not alert and oriented to person, place or time, he was confused, and he did not have safe decision-making capabilities. He was aware of his surroundings, he did not have a history of wandering, he had not attempted or expressed a desire to leave the health care center or expressed discontent, he had not attempted to leave home, he was easily redirected and did not have a diagnosis that required supervision. Record review of CR #1's nursing note dated 11/29/23 at 12:44 p.m. written by LVN A revealed CR#1 was exhibiting exit seeking behavior. The writer reached out to the MD to request wander guard monitoring order for resident safety. Call back pending. Record review of CR #1's nursing note dated 11/30/23 at 11:14 a.m. written by LVN A revealed a call was received back from the MD. A new order was received: May apply wander guard to resident. Record review of CR #1's MD orders dated 10/31/2023 - 1/27/24 revealed there was no order for wander guard listed. Record review of CR #1's nursing note dated 11/30/23 at 11:50 a.m. written by LVN A revealed he was picked up by the transportation company via wheelchair for a scheduled appointment. Resident dressed, alert, and in stable condition. Record review of the local police department report for CR #1 dated 11/30/23 at 3:54 p.m. revealed a citizen found; a male in a wheelchair sitting in the rain in front of a cancer center in (City). Male in the wheelchair exhibited signs of mental illness and identified himself as (CR #1). He could not remember which nursing facility he was living at. EMS was notified and transported CR #1 to local hospital. Record review of CR #1's Emergency Department Record dated 11/30/23 at 4:26 p.m. revealed, .Emergency Notes: Patient received from (name) EMS stating that he wanted to be checked out Patient was found wandering outside in the rain by someone driving and was then picked up and taken to (local police department). Once at the police department, they called EMS to have the resident taken to the ER Patient was asked if he knew where he lived and patient stated, I don't know. Noted to have wonder guard (sic) on right wrist, so this nurse started to call facilities to find out where the patient lived .no visible injuries . no complaints of pain or discomfort . confusion noted throughout conversations . Record review of CR #1's local hospital records dated 11/30/23 at 4:35 p.m. revealed patient was brought to ED for evaluation. EMS stated patient was brought from jail for medical check. Patient states he was with his friend helping him do work outside when he was brought to the hospital. Patient states his permanent home is in a rehabilitation hospital, but he does not know which one although he states he was there last night. Patient denies any current complaints . Re-evaluation/Progress #1 please note after patient arrived it was found out he is a resident of a nearby nursing home. They state patient went to doctors visit unsupervised and wandered out and then police found him and brought him to the hospital . primary impression: wandering. Record review of CR #1's nursing note dated 11/30/23 at 4:51 p.m. written by LVN A revealed the facility received a call from the transportation company to report her driver was on scene of appt to pick up resident and clinic staff stated resident refused to be seen by the MD and was no longer at their facility. The ADON was made aware. Record review of CR #1's nursing note dated 11/30/23 at 5:18 p.m. written by LVN B (previous ADON) revealed she received a call from the local hospital about resident currently being in ER . transportation arranged with transportation company. Record review of CR #1's nursing note dated 11/30/23 at 7:00 p.m. written by RN P revealed citizen returned from the local hospital at this time. No s/s of distress noted. Record review of CR #1's nursing note dated 11/30/23 at 7:05 p.m. written by RN P revealed CR #1's MD was notified of his return to the facility. During an interview on 1/25/24 at 10:11 a.m. with LVN A, she said CR #1's exit seeking behaviors were that he made comments about wanting to go home and was going toward the front of the building. She said he would roam the halls and ask where the doors were but said she did not remember him coming to the front or going out of the building. She said she called the MD, and he gave an order to place a wander guard. She said on the day of his appointment (11/30/23) CR #1 was alert and talking. She said she gave CR #1's paperwork to the driver which was their normal protocol. She said she did not believe any staff went with CR #1 because he was his own RP, alert, and oriented x 2-3 (oriented to person and place; oriented to person, place and time), and able to consent for care. She said the facility would send a staff if the resident was demented, nonverbal, and not able to verbalize their needs. She said they redirected him, and he was not exit seeking after placing the wander guard and he knew it was best for him to stay in the facility for his safety. She said his exit seeking was more of a temporary thing and based on his behavior that day, and she did not feel he was trying to leave the building. She said the transportation company went to CR #1's MD appt to pick him up but he was not there. The clinic told transportation he refused to be seen and they did not know where he went. She said she reported the information to the ADON and the ADON began to make phone calls. She said she did not do anything after that. She said it was facility's job to ensure the resident was safe and she would assume a staff member needed to go to the appointment to ensure he was where he should have been and not get lost. During an interview on 1/25/24 at 10:37 a.m. with LVN B (previous ADON), she said she was not aware CR #1 left the building or had an appointment. She said the nurses may have scheduled CR #1's appointment on a day she was not at the facility. She said she was not aware if anyone went with him, and it was not appropriate for him to go alone because he was confused and would not have answered questions. She said staff accompanied a resident if they did not have family, were not alert and oriented, and could not sign paperwork on their own. She said if she had known about his appointment, she would have sent staff because he had a wander guard. She said he wore a wander guard because it was reported he made comments about family and wanted to go outside and was ready to go home. She said he was never exit seeking or went to the door to try to leave. She said CR #1 had episodes of confusion and would make comments about family but did not have family. She said CR #1 could get in his wheelchair and roll around with no problems. She said the nurse (LVN A) informed her transportation called to see where he was because they could not find him. LVN B said she called the hospital, doctors office, transportation company, Administrator, and nurse management to locate the resident. She said the local hospital called the facility and notified them that he was there. When he returned to the facility, CR #1 told her his brother and sister picked him up and he did not know where they were taking him. She said after the incident occurred (on 11/30/23) the facility conducted in-services with them and said once a resident was out of the facility for 2 hours, call the doctor's office and check on them. She said the facility also hired a transportation driver to help take residents to their appointments. During an interview on 1/25/24 at 11:15 a.m. with the transportation company manager, he said (on 11/30/23) his driver picked CR #1 up from the nursing facility at 12:00 p.m. for a 12:45 p.m. appointment. He said Driver A dropped CR #1 off at the MD office, gave his paperwork and dispatch number to the office and asked them to call the number when he was ready. He said the office did not call about CR #1. He said it was unusual for residents to stay in the office after 5 p.m. so around 6 p.m. he instructed Driver B to go check on CR #1. He said the driver went to the office and it was closed. He said the driver did not see the patient or anyone else. He said the transportation company called the facility to notify them of the situation. During an interview on 1/25/24 at 11:22 a.m. with Driver B, he said he went to the office suite number to pick up CR #1, but he was not there. He said he and nurses at the office looked for him around the building but did not see him. During an interview on 1/25/24 at 11:32 a.m. with Driver A, he said the nursing facility told him to take CR #1 to his appointment but did not give any special instructions. He said it was raining a little bit that day. He said he handed the receptionist the resident's pamphlet and transportation number to call when he was ready, and left CR #1 in their care. He said CR #1 seemed slighty off but was still cognizant. He said the facility did not send anyone to accompany CR #1. During an interview on 1/25/24 at 11:52 a.m. with LVN A, she said she received an in-service after the incident on 11/30/23 that if a resident went out and was gone for 2 hours she should call and check on the resident. She said she was also in serviced on sending a staff out with the resident. During an interview on 1/25/24 at 1:15 p.m. with the Administrator, she said she did not know why a CNA did not accompany CR #1 to his appointment and she did not make the arrangement for his appointment that day. She said she did not feel CR #1 was appropriate for a wander guard because there was no consent for it. She said the facility did not report the incident because they decided he was his own RP, did not have a dementia diagnosis and decided to leave the appointment on his own. She said prior to the appointment he was not a wander guard resident. She said she was unsure if he had dementia or confusion. She said it may have been her fault that CR #1 ended up with a wander guard because there was an incident where he went out of the front door pushing a bedside tray. She said she did not know enough about CR #1 and did not know if he needed to be supervised at his appointment or not because the situation was fluid. She said the residents had autonomy and the facility had to allow them to make their own decisions. She said she expected the MD office to notify the facility or call the transportation company. She said the nursing facility was responsible for all resident who wore a wander guard or not. She said she was unsure if an incident was documented on it. She said the facility hired a van driver, but it was not because of the incident and the position was planned since October. Interview on 1/25/24 at 3:24 pm with LVN A, she said CR #1's MD gave the order for the wander guard, and she put it in the system. She said she did not remember who put the wander guard on the resident, but she knew it was placed because she saw it on him. Interview on 1/25/24 at 5:32 p.m. with CR #1's MD, he said he did not remember the circumstances around why CR #1 needed a wander guard. He said he remembered the wander guard came up but he personally did not write an order. He stated the facility may have written the order under his name. He said CR #1 could wander because he had some degree of confusion. He said the resident was very confused at the hospital but then became less confused at the facility. He said he was not aware of the details of CR #1 leaving his appointment. He said if a resident wore a wander guard, someone should go out with them. He said the EMS transportation and/or clinic bore some responsibility. Record review of LVN A's Performance Feedback dated 12/4/23 read in part, . this is an opportunity for improvement . Description: elopements, wander guard appropriateness, and appointments . Record review of the facility's Managing Dr's Appts in-service dated 12/4/23 conducted by RN T read in part, .if a resident requires to be accompanied for a Dr's appointment, please communicate with the scheduler to see if someone can go with the resident if not, the appointment should be re-scheduled. For the residents that go without being accompanied, if they are not back at the facility in at least 3 hours, call the Dr's office and find out if everything is okay (depending on the type of appointment). Residents who are cognitively impaired must always be accompanied. There were 25 signatures on the in-service. Record review of the facility's morning meetings notes dated 1/2/24 - 1/26/24 provided by the DON revealed residents with appointments for the day were listed on the notes. Record review of the facility's Resident Rights: Transportation policy dated 1/27/21 read in part, .the facility provides safe and efficient transportation as available, and in collaboration with community transportation providers to meet patient and resident needs . Procedures .9. Transportation is provided for medical appointments .B. Nursing staff or designee will provide handoff information to the receiving entity and may include but is not limited to continuity of care document, labs, consents, MARS, TARS, face sheet .17. The facility will encourage family to transport and participate in appointments and outings when the conditions for safety and infection precautions are possible .19. Transportation Aid will accompany as deemed necessary by facility leadership . On 1/26/24 at 9:40 a.m., the Administrator was notified of the Immediate Jeopardy due to the above failures. The IJ template was left with the Administrator and a plan of removal was requested at that time. The following Plan of Removal (POR) was submitted by the facility and accepted on 1/26/24 at 4:55 p.m.: PLAN OF REMOVAL F689 Name of facility: (name) Date: 1/26/24 Immediate action: CR #1 is no longer residing in the facility as of 12/1/23. Review of recent BIMS of current residents was completed by Director of Nursing/Designee on 1/25/24 to identify residents with BIMS of less than 8 and wearing a wander guard for exit seeking behaviors. 4 residents identified as having a BIMS less than 8 and wear a wander guard for exit seeking behaviors. Review of upcoming appointments was completed by Director of Nursing/Designee on 1/25/23 to identify upcoming appointments for residents with BIMS of 8 or less and wearing a wander guard for exit seeking behaviors. None identified. Review of recent BIMS of current residents completed by Director of Nursing/Designee on 1/26/24 to identify cognitively impaired residents, with a BIMS less than 8. Seventy-five(75) residents identified. Review of upcoming appointments was completed by Director of Nursing/Designee on 1/26/23 to identify upcoming appointments for cognitively impaired residents. 2 residents with BIMS less than 8 were identified to have appointments on 1/26/24. Both residents have someone scheduled to accompany them to these appointments. Reeducation provided to Director of Nursing and Administrator by the Clinical Consultant on 1/26/24 on need for family/Responsible Party or facility staff to accompany residents with a BIMS of less than 8 or residents wearing a wander guard for exit seeking behaviors. Re-education provided to licensed nurses and certified nursing assistants on need for residents with BIMS of less than 8 or residents wearing a wander guard for exit seeking behaviors to have a family member/Responsible Party or facility staff accompany them to outside appointments. This education was completed by 1/26/24 by the Director of Nursing. Any licensed nurse or certified nursing assistant not receiving this education by the target date will receive prior to their next scheduled shift. A review of the day's outside appointments will be completed in clinical morning meeting Monday - Friday by the Administrator to validate any resident with a BIMS of less than 8 and any resident wearing a wander guard for exit seeking behaviors has a family member/Responsible Party or facility staff member scheduled to accompany them. This will begin on 1/29/24 and continue Monday - Friday. The Nurse Managers will communicate to the licensed nurse verbally and by writing on the 24 hour report that a resident will have a family member/Responsible party or staff member accompany the resident on an appointment. Licensed Nurses will validate residents with a BIMS of less than 8 or residents wearing a wander guard have a family member/responsible party or facility staff accompaniment with them prior to the resident leaving for any outside appointment. Licensed Nurses will validate prior to the end of their shift any resident who has left for an appointment without an accompaniment has returned. If the resident has not returned, the licensed nurse will follow up with the office staff at the appointment for an update on the resident and this will be communicated to the next shift. Elopement Policy was reviewed on 1/26/24 by the Administrator and Director of Nursing and no changes were indicated. Ad Hoc QAPI was held on 1/26/24 to review the contents of this plan. The Medical Director was notified on 1/26/24 of the Immediate Jeopardy and the contents of this plan. MONITORING Record review of the facility's Quality Assessment and Assurance Meeting Minutes dated 1/26/24 signed by the Medical Director, Administrator, and DON revealed the IJ template was attached. Record review of the facility's BIMS score and appointments in-service dated 1/26/24 conducted by the Corporate RN revealed the objectives of the in-service were: -train the trainer -BIMS score - what does it mean? Why is it important? -Outgoing appointment - residents with a BIMS of 8 or below may need to be supervised* *dialysis appointments might be an exception. The in-service was signed by the Administrator and DON. Record review of the facility's Managing Dr's Appt. in-service dated 1/26/24 revealed all nursing staff were to ensure that residents with BIMS or less than 8 and wearing a wander guard exit seeking behaviors to have a facility staff accompany them to any outside appointments. There were 40 signatures on the in-service. Record review of Order Report by Category (Safety Devices) dated 1/26/24 revealed there were 5 residents who wore a wander guard and 4 of the 5 residents had a BIMS score less than 8. During an interview on 1/27/24 at 9:36 a.m. with the MDS nurse, he said he received in-services on 1/25/24 and 1/26/24 on all patients going out to an appointment who have a BIMS score of 8 or below would have family or staff go with them and remain. If no one was able to go, the appointment would be rescheduled. He said the nurse caring for the patient was provided with a current list of patients BIMS score. He said they reviewed the wander guard policy and any patient wearing a wander guard absolutely had to have someone accompany them to the appointment. During an interview on 1/27/24 at 9:46 a.m. with Transportation Aid, she said she was trained to ask the nurse for the resident's BIMS score. If it was 8 or lower, she would stay at the appointment with the resident. At dialysis, she would stay with them until they were called to the back by staff. She said she would ask the staff for estimated pick up times. She said she was provided with a list of residents who wore wander guards, and she would have to stay with them at the appointment. She said the majority of time, family would meet them at the appointment. She said if a resident was not at the appointment at pick up, she would ask the office where they were and would then call the facility. During an interview on 1/27/24 at 11:38 a.m. with LVN J, she said she was in-service on appointments. She said any resident with a wander guard needed an escort. She said they looked at the resident's score to see if it was safe for them to go alone. She said if it was unsafe staff would go out with the resident because it was too dangerous. During an interview on 1/27/24 at 12:01 p.m. with CNA T, she said if a resident had a BIMS score of 8 or less, they had to be accompanied to an appointment by a CNA for safety. She said if a resident had not returned, she would notify her nurse. She said residents with wander guards for elopement required supervision as well because they would wander. During an interview on 1/27/24 at 12:27 p.m. with CNA E, she was in-serviced on appointments. She said there was a list of residents that indicated if staff had to go with them or not. During an interview on 1/27/24 at 12:35 p.m. with RN K, she said residents with a BIMS lower than 8 or who had a wander guard would be discussed and need to have staff accompany them to an appointment. She said if a resident who went unaccompanied had not returned, she would call the office to see where they were. During an interview on 1/27/24 at 1:06 p.m. with the DON, she said residents with a BIMS of 8 or below or resident with a wander guard would be sent to an appointment with either staff or family. She said the nurses would check on the resident if they were able to go unsupervised and were not back from their appointment. During an interview on 1/27/24 at 2:45 p.m. with the Administrator, she said the Corporate RN trained her on appointments. She said if the resident had a low BIMS, someone would accompany them. If they had a wander guard, a family member would attend. She said during every morning meeting, resident appointments were discussed and if they were accompanied or not. She said if a resident had not returned, the nurse would be on alert and call the office. The facility was notified the IJ was removed on 1/27/24 at 3:30 p.m. however, the facility remained out of compliance, at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their corrective systems.