**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #139) resident of three residents reviewed for assisted transfer. The facility failed to ensure on 02/01/2024 PT K used the Hoyer lift ( mechanical/patient lift designed to assist caregivers move patients from one place to another) correctly, attach the Hoyer lift sling pad and condcuted with assistance of a second person as care planned, when he transferred Resident #139 from his wheelchair to the bed. On 02/01/2024 Resident #139 fell from the Hoyer lift sling pad while in use fracturing the right clavicle (right shoulder), right femoral neck (hip), right proximal tibia fracture (long bone in the right lower leg) and sustained an intraventricular hemorrhage (bleeding into the brain). The noncompliance was identified as PNC (past non-compliance). The Immediate Jeopardy(IJ) began on 02/01/2024 and ended on 02/03/2024. The facility had corrected the noncompliance before the survey began. The failures placed residents at risk for harm and/or serious injury, hospitalization, a decline in health, and death. Findings included : Record review of Resident #139's quarterly MDS assessment, dated 04/25/2024 reflected the Resident was a [AGE] year-old-male who admitted to the facility on [DATE] and discharged on 05/07/2024. The resident had diagnoses which included: Diabetes (increased blood sugar), dialysis (kidneys do not function have to have machine to cleanse blood), osteoporosis (brittle bones), left above knee amputation (leg missing from above the knee downward) and Protein malnutrition (poor nutrition). The MDS reflected he had a BIMs score of 12, which indicated moderate cognitive impairment and the resident was dependent on two or more staff members to transfer him from bed to wheelchair. Record review of Resident #139's care plan, dated with a review/revise date of 06/13/2022, addressed the resident's activities of daily living needs, requiring mechanical aide for transfers for chair/bed transfers (requiring two staff), and risk for falls and assistance required for activities of daily living. Further review of the clinical record reflected, the care plan was updated quarterly, addressing the transfer bed/chair needs requiring mechanical assistance and two staff members, until discharge on [DATE]. Record review of Resident #139's Fall Risk Assessment completed 06/09/2022 and quarterly thereafter scored Resident #139 as high risk. Further review of the clinical record reflected on 02/06/2024 a follow-up fall risk assessment was completed after hospitalization; Resident #139 was still a high risk for falls. Record review of the Provider Investigation Report, dated 02/02/2024 and completed on 02/07/2024, revealed Resident #139 was total assist for activities of daily living and had fallen during a Hoyer lift transfer with the Physical Therapist K on 02/01/2024 at approximately 4:00 p.m. Resident #139 had been transferred by PT K without any assistance from other staff and the PT knowingly attached the Hoyer lift sling/pad incorrectly. The transfer resulted in Resident #139's injuries: 1) right distal clavicle fracture, 2) the right proximal tibia fracture, 3) right intertrochanteric femoral neck fracture, and 4) intravascular hemorrhage of the brain. Resident #139 had to be transferred from the local ER to a larger hospital for further evaluations of his injuries. The Provider Investigation Report reflected a finding of confirmed (incident). The facility suspended the physical therapist and then later terminated,due to the PT admited he did not follow the policy for mechanical transfer (Hoyer lift). The facility started an in-service on fall prevention, transfer, and abuse/neglect policy and procedure with all staff and conducted competencies for mechanical lift training, Hoyer lift competency check off, and transfer training with a gait belt, was performed on all staff who transfer residents prior to returning to care with all staff. Review of the Provider Investigation Report dated 02/01/2024 and completed on 02/07/2024, reflected a finding of substantiated for an incident based on the Physical Therapist's interview. The physical therapist in the interview admitted the Hoyer lift transfer of Resident #139 was conducted without following policy of the facility, including two staff members for the transfer, and attaching the Hoyer lift pad/slip correctly. Review of the External/Internal/Systemic Approach Investigation Summary dated 02/02/2024 completed on 02/07/2024 reflected: There was an emergency QAPI meeting was held on 02/02/2024 with Medical Director in attendance. The meeting concluded all residents had a safe survey interview completed with BIMs score greater than 10 (no concerns about transfers noted), staff interview initiated, facility inspected lift sling and equipment to check for failure. (No failures of equipment or sling were identified), in-services began on all staff that care directly for residents, concerning Hoyer lift transfer, gait belt transfers, falls, abuse, and neglect. Who was responsible for in-servicing: Nurse Management. Who will monitor: Regional Director of Clinical Services/Director of Nursing. In additional meeting the QAPI decided, The Nursing Administration, including the ADON and DON will randomly select five staff for Hoyer lift transfers demonstration each week to continue since February 2024. The DON will monitor for compliance for 8 weeks and then on 04/02/2024 QAPI decided to continue the five employee's observation of transfer training a week ongoing basis. This training is including new hires, CNAs, Nurses, MAs, and therapists. Who will monitor: The Administrator will continue to monitor and oversee the training by reviewing with the DON the weekly trainings in the morning meeting. Resident care plans will be reviewed and updated about the transfer needs. Audits will be ongoing basis and compiled into a binder that the DON maintains. The binder was reviewed with the DON and the Surveyor. Further review of the Provider Investigation Report reflected monitoring and audits by the designated staff (the DON and Nurse Managers) had occurred. Record review of the nursing progress notes reflected on 02/01/2024, the PT reported to and doucmeneted by RN L at approximately 4:30 p.m. that Resident #139 had slipped from the Hoyer lift during a transfer. RN L observed Resident #139 in the room lying on the floor, next to the bed with a pillow under his head. The RN assessed the resident due to complaint of pain to his bilateral (both) hips, right toe, right temporal mandibular joint (right cheek), and right shoulder. The RN called the family and the physician ordered x-rays. Further review of the progress note reflected Resident #139's x-rays results at 5:46 p.m. were questionable for a right distal fracture and proximal tibia fracture, positive for right intertrochanteric femoral neck fracture, and right clavicle fracture. The physician was notified of the results of the x-rays, orders were given to transfer the resident to the local hospital. The family was notified of the results and the transfer to the hospital. Record review of the nursing progress notes dated 02/06/2024, at aporximalty 2:20 p.m. documented by RN L reflected Resident #139 on 02/06/2024 returned from the hospital with a right hip fracture and right shoulder fracture. Orders noted for Physical Therapy, Occupation therapy, and Speech therapy. Resident #139 remained a total assist for transfer with two staff members using a Hoyer lift. In an interview on 08/20/2024 with PT K at 9:30 a.m. revealed PT K knowingly with no assistance from another staff member, transferred Resident #139 using the Hoyer lift. PT K stated no other staff was asked to assist with the Hoyer lift transfer. PT K stated there was plenty of staff and a CNA assigned to Resident #139. PT K stated the Hoyer lift sling pad was not hooked appropriately, the sling pad was not fully clipped to the sling loop onto the lift hook, causing the loop to slip off. The sling pad became undone, and the resident slipped out and was eased to the floor. PT K could not explain if the resident was eased to the floor how so many injuries had occurred. PT K stated that Resident #139 hit the floor hard. The PT stated a pillow was placed under the resident's head and the nurse was informed. PT K admitted to knowing and understanding that the facility policy and the training specified that lift transfers required at least two staff, but he did not offer any reason as to why he did not follow policy for a safe transfer. PT K stated he could not come back until the investigation was completed. PT K stated he made a very poor decision, but it was an accident. PT K stated the facility terminated his position in the facility. The PT stated he was a four-year degreed PT with a doctorate degree and he knew the importance of a safe Hoyer lift transfer. The PT stated in-services were given concerning Hoyer lift transfer and how to appropriately perform them, by PT K, at this facility. An observation on 08/20/2024 at 11:00 a.m. revealed Resident #140 was transferred by Hoyer lift. CNA M and CNA N transferred Resident #140 appropriately to the wheelchair with no pain or anxiety related to the resident. CNA M and CNA N both stated there had been multiple in-services on Hoyer lift transfers, including appropriately securing the lift sling/pad. Both CNAs stated they had been tested after the training and one of the CNAs stated there was random competency testing. In an interview on 08/20/2024 with RN L at 1:45 p.m. revealed the PT came and reported Resident #139 had slipped out of the Hoyer lift , while being transferred. The RN stated there was no other staff in the room when Resident #139 was being assessed for injuries. The family and the physician were notified, x-rays were ordered, and the result of the x-rays indicated there were fractures to the shoulder and possible tibia and possible hip, all on the right side. Resident #139 was sent to the hospital when the results of the x-ray came back. RN L stated PT K stated Resident #139 was transferred in the Hoyer lift by the PT with only one person and the sling/pad had come undone and the resident had slid out of the Hoyer lift onto the floor. Resident #139 was hurting all over and denied hitting his head. RN L stated when a resident had a fall the resident was assessed, and the physician and responsible party were informed. They followed physician's orders and then reassessed according to the physician's orders and the injures. The RN stated the ADON, and the DON would be notified when a resident had a fall and had to go to the hospital. The RN sated the entire staff had to have the transfer in-service concerning gait belts and Hoyer lifts before working on the floor after Resident #139 fell from the Hoyer lift. The RN stated the facility had in-serviced the entire care staff and the therapists, and the facility had continued to randomly select staff and have them Hoyer lift transfer a resident or another staff member. In an interview on 08/22/24 at 10:00 a.m. with the DOR revealed the PT had been trained on all transfer methods including the use of the Hoyer lift. The PT had even given in-services concerning the Hoyer lift and how to transfer a resident safely and appropriately. The DOR could not recall how long ago. The DOR stated the PT had worked at the facility for 7 years as a Physical Therapy Assistant, then got accepted into therapy school completed and gotten his doctorate and passed the board. The DOR stated it was shocking to hear how the PT had transferred Resident #139. In an interview on 08/22/2024 with the DON at 4:00 p.m. revealed the RN had contacted the physician and the responsible party when Resident #139 had fallen. The x-rays were positive for injuries and the investigation was started by the Administrator and DON. The DON stated the PT admitted to inappropriately transferring the resident and not following the company policy for Hoyer lift transfer. The resident's family was contacted, and the family had decided to bring the resident back to the facility as they were satisfied with how the facility had conducted the investigation and the outcome. The DON stated the PT had been trained on the policy and procedure for Hoyer lift transfers and had even given some of the in-services at the facility. In an interview on 08/22/2024 with the Administrator at 4:15 p.m. revealed the staff had all been in-serviced on Hoyer lift transfers, gait belt transfer, and abuse and neglect starting on 02/02/2024 and the in-services continued for the nursing and therapy departments given by the DON and ADON with competency testing. The DON and ADON choose five different staff off different shifts during the week to perform Hoyer lift testing. He stated the Quality Assurance team decided in April 2024 to continue with that part of the plan. The Administrator stated the PT had been suspended on 02/01/24 and had immediately been dismissed, as soon as the injuries were verified. The PT admitted completing the Hoyer lift transfer and not following the company policy of always having two staff and using appropriate safety concerning the Hoyer lift sling pad. The Administrator stated the staff had been in-serviced on safe transfers and the expectations of the Administrator. In an interview on 08/23/2024 at 1:00 p.m. with LVN O revealed Resident #139 had been on the rehab hallway. LVN O stated Resident #139 was a very pleasant man, who had originally admitted to the facility to get stronger and learn to use a sliding board since his left leg was an above the knee amputation. Resident #139 did not accomplish the sliding board safely and then had to be transitioned to a Hoyer lift transfer and remained a Hoyer lift transfer the entire stay at the facility. The resident was not on the rehab hallway the entire time. LVN O stated after the fall occurred the entire direct care staff had been in-serviced with competency testing on different types of transfers to include Hoyer lifts. The Hoyer lift required two staff members, it always had. The LVN stated the testing continued by the DON and ADON even now for Hoyer lift transfers, to make sure the staff understood the safety measures and always had two staff members, as well appropriate use of the lift sling pads. The LVN stated it was shocking that the PT had not gotten assistance to transfer Resident #139. In an interview on 08/22/2024 at 3:30 p.m. with the Medical Director revealed the facility had been contacted when Resident #139 had fallen and had serious injuries. The Medical Director stated there was a QAPI meeting the next day and was plan was put into place to educate and prevent a similar incident from happing again. The PT was terminated, and it was suggested that the PT be referred, which is in agreement. The Medical Director stated the facility was very good about communicating to him concerning changes of conditions with the residents. Review of the incident and accident logs dated 01/01/2024 through 08/20/2024 reflected no other incident /accidents related to the Hoyer lift transfers. Resident #139 had no other incidents or accidents related to transfer with a Hoyer lift. Review of an in-service dated 02/02/2024 reflected all staff attended and the subject matter was regarding the facility policy on falls, Hoyer lift transfers, and gait belt transfers with the competency testing for each transfer by each individual staff member. Further review reflected additional continued random testing one time a week for random selected staff for Hoyer lift transfers and education. Review of the Facility's Policy titled Hoyer Lift revised and dated May 2024 reflected: It is the policy of this facility that the Hoyer lift will be utilized for resident transfers only. It will not be used to transport resident to another location. Assistance of two personnel will be used with Hoyer Lift Equipment . Hoyer lift , Hoyer Lift sling 6. Position seat sling .8. Attach S/hooks of the lift to the holes in the Hoyer sling. Insert hooks away from the resident to outside of sling .9. Count links to be sure there are the same number on each side. Check to see that S/hooks are hooked all the way into the loops and that the sling is closed to the knees for safety .11. Check S/hooks to makes are properly positioned

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement for 1 of 1 (Resident #133) reviewed for accidents hazards/supervision. The facility failed to implement interventions to prevent elopement and failed to adequately supervise Resident #133 to prevent him from leaving the facility on 06/05/2023 without staff knowledge. Resident #133 was located 0.4 miles away from the facility. This failure could place residents requiring supervision at risk for serious injury and death. In Immediate Jeopardy (IJ) was identified to have existed from 06/05/2023 to 06/05/2023. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. The facility took the following actions to correct the non-compliance: moved Resident #133's room close to the nurse's station and placed a wanderguard bracelet on Resident #133. The facility Administrator was provided the IJ template on 06/30/2023 at 12:24 PM. Findings included: Record review of Resident #133's face sheet, dated 06/30/2023, revealed he was a [AGE] year-old male admitted to the facility on [DATE] from a skilled nursing facility with a primary diagnosis that included surgical aftercare following surgery on the digestive system and other diagnoses that included muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, alcoholic cirrhosis of liver without ascites, heart failure, hypotension, acute kidney failure, and benign prostatic hyperplasia. Record review of Resident #133's MDS, dated [DATE], revealed a BIMS score of 10 indicating moderate cognitive impairment. Further review of the MDS revealed Resident #133 had wandering behavior 1-3 days upon assessment and required extensive one person assist for bed mobility, toileting, and personal hygiene and required the use of a walker and wheelchair for mobility. Record review of Resident #133's care plan, dated 06/03/2023, revealed Resident #133 had an indwelling catheter, was an elopement risk with history of attempts to leave the facility unattended x1 on 06/05/2023, and at risk for falls. Record review of Resident #133's Nurse note on admission dated 06/02/23 at 8:35 PM by LVN T revealed he was alert and oriented x 2 at times . but very confused . had a healing surgical wound to his abdominal area with a Jackson Pratt drain present . foley-cath . with urine dark [NAME] with traces of blood and bruising to both hands, arms, and lower abdominal area. Record review of Resident #133's Nurse Note dated 06/05/23 at 8:30 AM by LPN L revealed the resident in bed holding [Jackson Pratt] JP drain after self removal. Record review of Resident #133's Nurse Note dated 06/05/23 at 11:45 AM by DON revealed IDT team note: resident with a BIMS of 10 . Resident states 'I left to go get some food from one of my favorite restaurants.' Physician and LVN D and was at bedside and completed head to toe assessments. No injuries noted at this time. Resident had a few episodes of minimal low-level confusion. New order for wander guard placed. Wander guard placed at this time. Resident is cooperative and not attempting to wander or elope at this time . Resident being moved to a room close to nurse station for increased observation. Record review of Resident #133's Nurse Note dated 06/05/23 at 12:48 PM by LPN L revealed Notified of resident being out of the building this AM. Code green activated. Resident returned to building via staff via wheelchair. Head to toe assessment performed no new injury noted no decrease in ROM noted. Wander guard attached to right ankle. Resident stated, 'I don't like the food and went to go get something to eat.' Record review of Resident #133's Nurse Note dated 06/06/23 at 1:30 AM by RN O revealed Patient found lying on the floor next to his bed, appeared confused, unable to describe what he was trying to do. Patient might have slid off the bed with bed in the lowest position, no complaint of pain, no injuries this time, vital signs stable, neuro checks started . Record review of Resident #133's Nurse Note entries dated 06/06/2023 at 7:23 AM and 06/07/2023 at 7:07 AM by RN G revealed Continues to exit seek . no late injury noted . Record review of Resident #133's elopement/wandering evaluation, dated 06/02/2023, revealed a score of 28 out of 55, indicating a high [elopement] risk. Record review of Resident #133's elopement/wandering evaluation completed after elopement, dated 06/05/2023, revealed a score of 17 out of 55 indicating a high risk. Record review of Resident #133's June 2023 TAR reflected, monitor placement and functioning of wander guard every shift, if wander guard is nonfunctioning replace immediately -Order Date- 06/05/2023. Record Review of 24-hour report dated 06/02/2023 reflected, Admissions - Resident #133, [room number] full code, Dx hernia repair, Abd - JP drain empty every shift, Foley Catheter 16Fr/10mL, Alert and Oriented x2 forgetful, assist x1, P.O. med. Record Review of 24-hour report, dated 06/04/2023, reflected Resident #133 .repeat BMP, low/decreased Sodium. Record Review of 24-hour report, dated 06/05/2023, reflected Resident #133 JP out, moved, eloped, wanderguard, room number]. Record Review of the Provider Investigation Report (PIR) revealed based on camera surveillance, around 09:50 AM on 6/05/23, patient wheeled himself out of his room, down the hall toward the short-term care nurses' station. At 9:53 AM, Resident #133 goes out of camera view as he entered a foyer/sitting area for the short-term care entrance to the facility. At that point he is no lover visible by camera surveillance. Around 10:45 AM Resident #133's roommate (from his home residence) called the facility to inform us that Resident #133 was at a neighboring restaurant. At that point in time the facility was alerted to a Code Green elopement . Around 10:50 the Administrator and DON found Resident #133 at the restaurant and asked if he was okay. He explained he lives nearby and likes this restaurant and would stop by to get something to eat. Investigation notes revealed Resident #133 responded that he did not want to go back to the facility and was going to have his roommate come pick him up, but the roommate was in a meeting and could not come right now but was hopeful he could get a ride later. At this point Resident #133's second resident representative and her husband showed up at the restaurant to help persuade the resident to return to the facility. Further review of the PIR revealed resident returned to the facility in the facility van. The Facility Investigation Summary reflected, investigation found that Resident #133's medical records did not indicate any previous elopement attempts or wandering behaviors at [hospital/facility names]. The investigation found that Resident #133 had a change in condition with improved mobility, increased confusion and exit seeking desires . Observation of facility grounds when exiting the main door and rehab door revealed the outside area and parking lot was unsecured and led to residential streets and a major highway. [restaurant name] was located 0.4 miles away from the facility. Observation and interview of Resident #133 on 06/28/2023 at 04:16 PM, revealed the resident was well groomed and dressed, lying in bed, wearing nonskid socks and a gray ankle bracelet. When asked about the elopement, Resident #1 stated that he does not normally act like that, they [staff] were very concerned and did those tests and found he had a UTI. Resident #133 said the staff would not let him go outside now because they think he would run away. Resident #133 stated he actually thought he was somewhere else, and he was trying to leave because he was hungry and knew of a place close by. Resident #133 said the day he left, 4 people came to the restaurant to get him, 2 guys that worked at the facility and 2 of his friends. Resident #133 said he was not injured that day. Resident #133 said the ankle bracelet was to keep track of him. Interview with LVN F on 06/28/2023 at 04:26 PM, revealed he remembered the incident, but it happened on the first shift when he was not there, and since then they have monitored Resident #133 every 2 hours, and his wander guard would set off the alarm if he left the building. LVN F stated the resident has been very compliant and has not tried to get out since. LVN F said Resident #133 did not try to leave before that incident. LVN F stated if a resident was an elopement risk they have alarms and staff check on them. When asked what you do when a resident elopes, LVN F stated once identified the resident has left, check all the rooms and facility, if we don't find them, we make an announcement so everyone tries to find the person, go outside and look around. When we find them, bring them in, inform family, let the DON know and an incident report. LVN F said we want to make sure the person is ok and no harm, let the doctor know and if the doctor wants labs, psych evaluation or whatever is necessary. LVN F said they use wander guards if the resident was a risk, get a doctor order and explain to the resident that it was a little gadget to allow staff to know where they were at all times and if they try to leave the alarm would go off. LVN F said some residents understand it was for their safety but some get confused. Interview with Resident #133's Emergency Contact/Representative on 06/29/2023 at 10:23 AM, revealed Resident #133 lived independently prior to being at the facility, had been in the hospital since 04/11/2023, and she was aware of the elopement incident. She stated Resident #133 had wheeled himself out of the facility, and at the time was on his meds, had a UTI and was trying to escape. He was trying to get home or a place where he would go quite frequently, something familiar. She said Resident #133 thought he left his truck there [at the restaurant] and could not find it so called one of his friends to pick him up. She said that friend knew better so he called another friend (Resident #133's second listed representative) and that representative called the facility. The Emergency Contact stated Resident #133 had no past wandering or elopement behaviors, but he had liver disease and when on the UTI meds he started imagining things and remembering things from before and just got confused. Interview with LVN D on 06/29/2023 at 10:50 AM, revealed he was not able to answer what elopement interventions/monitoring were in place for Resident #133 upon admission, but the wanderguard was put on after the fact. When asked what you do if an elopement risk was high, LVN D stated that was evaluated when they came in and the wanderguard was not put on at first but at attempt or when they have made an attempt to leave. LVN D said he was not on the floor and was in the morning meeting when Resident #133 left and was later told he went out about 15 feet from here (he pointed at the rehab entrance and not main building entrance) and exited the door from the lobby. LVN D stated there was a code to enter before leaving but were also fire doors so if pushed long enough the door would open. LVN D stated he saw Resident #133 lying in bed about 9:30 am on 06/05/2023 on his last round before going to the morning meeting. LVN D stated when a resident elopes and gets out, a code green was called, they search the building and then if they cannot find the resident, they work the surrounding area. LVN D stated the had a code green drill last month. LVN D stated he does not usually do elopement assessments because admissions come in on the evening shifts but during the day if he notices wandering or exit seeking behaviors, he would let the ADON or DON know and it was communicated on shift change. Interview with Resident #133 on 06/29/2023 at 11:10 AM, revealed when he admitted he was in another room and the morning he left there was a receptionist sitting in the lobby and told her he was going to get something from the truck and opened the door or went out with some other people, and did not remember if the door alarm went off. Resident #133 stated this happened about 10:15 AM, and he did not know the names of the streets he took but took the side and residential roads because he did not want to take the highway. He said he was tired when he got there, was not scared, and was going to come back. He said he thought he could come and go but they changed hisroom when he came back. Interview with CNA E on 06/29/2023 at 11:34 AM revealed he worked that day (06/05/2023) and was doing something for another resident when Resident #133 was gone and all the people tried to find him. CNA E stated the alarm was currently working on the door and after the resident came back, he was moved to his (CNA E's) assigned hall because the resident was trying to go outside. CNA E stated if a resident eloped he would report to the nurse, search all the rooms, closets and outside the building. Interview with CNA C on 06/29/2023 at 12:16 PM revealed she worked with Resident #133 on 06/05/2023. She stated she did rounds from down the hall, got him dressed and in his wheelchair around 9:45 or 9:50 AM and asked him if he was going up front. The resident said yes, he was going to roll up their himself and she went to another room to assist another resident and that was when they got the alert. CNA C stated the last time she saw him he was going to do therapy and did not see him leave the facility and did not see any exit seeking or wandering behaviors that day and put a wanderguard after the incident. CNA A stated they make sure to keep an eye on him, have a routine, walk back and forth down the hall and check on them to make sure everybody was fine. She stated she did get training on elopements before the incident and if a resident tried to leave how to alert everybody, how to approach the resident and try to get them back in. CNA A stated Resident #133 did have a catheter and she put it on his chair with a privacy bag that morning and therapy was always in that area because they sit there and work with residents, but no one was assigned to sit at the entrance. She stated they did complete a code green drill before the incident and where they told us how to get the resident in, what areas to look and that everybody has to look. Interview with DON on 06/29/2023 at 01:12 PM revealed the DON, ADONs, and Clinical Resources do quarterly elopement drills and then review. He stated they had an elopement incident on 06/05/2023 and the drill was a week earlier on 05/25/2023 so they reviewed and had an in-service. He stated we go over the process and take a resident in an office or conference room therefore providing a live demonstration. He stated if a resident was an elopement risk they do a new assessment, and if they are confused the first intervention was the wanderguard but if not confused, do other interventions, because we cannot use a wanderguard on an alert and oriented resident as it would be considered a restraint. Other interventions included talking with them, frequent checks, assess, move the resident closer to the nurses' station and alert staff of needing to watch the person, talk with the family, and care plan. The DON stated the administrator did the investigation, and they do have cameras in the building, but do not cover every exit and the door he went out does not have a camera. He stated there is a code to open the door, and the alarm was currently functioning. He stated there was a front entrance way that therapist's work by but it was not their job to monitor who comes in and out and there was no receptionist at that entrance. The DON said the elopement drills included other departments, they call code green on the intercom, and everyone stops what they are doing to look for the resident. The DON stated Resident #133 admitted on the 2 to 10 shift and the nurse did an inaccurate assessment for elopement that included mental illness, but the resident did not have mental illness. The DON stated he redid the assessment after the elopement and it scored in the 20s but it was a horrible assessment because you can be an 11 and be high risk, there was not middle. There could be a lot of people that score high who are not appropriate. The DON stated Resident #133 had slight confusion at the time of elopement. When asked what interventions were done at the time prior to elopement, the DON said frequent monitoring, assess the patient check frequently and make sure they are OK but the monitoring was not charted. The DON said Resident #133 had a catheter at time of elopement and transported in a wheelchair. He said the resident lived in the neighborhood and went to his favorite restaurant and post elopement interventions included head to toe assessment with no injuries, physician and family notification, got an order for the wanderguard and moved to room [ROOM NUMBER] by the nurses' station, education, monitoring and a care plan meeting. The DON stated Resident #133 did have a fall on 06/06/2023 about 15 hours after elopement in the middle of the night. He said fall precautions were in place that included low bed, call light in reach, checking on him and not low on staff that night. After the fall, an Xray showed an injury that was found to be chronic and the family confirmed that he had a problem with the hip, if he had an acute injury the CT scan would have showed that. The DON said since elopement, Resident #133 did not have any other elopements or falls. The DON stated his expectation was for nurses to alert him when residents were exit seeking. Attempted interview with LVN T on 06/29/2023 at 02:15 PM by telephone was unsuccessful. Interview with Weekend Supervisor on 06/30/2023 at 10:08 AM revealed he worked the weekend on 06/03/2023 and 06/04/2023 and did not observe any wandering behaviors from Resident #133. He said he did check on Resident #133 that weekend, and all staff check on our residents, make sure the doors are not beeping, especially new residents on that hall they monitor closely but he did not get any reports from the nurses that Resident #133 was close to the door. He stated when he came back the next weekend the resident was moved. He said according to the assessment, if the resident was a high elopement risk and they were confused they use a wanderguard and made sure it was in place every shift, but if not confused they closely monitor behaviors like exit seeking, keep eyes on them and monitor. He said if the person has a wanderguard they are monitored every 2 hours and if no wanderguard then every hour. Interview with Administrator, DON and Clinical Resources on 06/30/2023 at 12:24 PM, they said up until the point Resident #133 eloped, he had not tried to. Record reveiw of Emergency Prepardeness DRILL - Missing Person/Elopement dated 05/25/2023, revealed LVN D, CNA C, and CNA E participated in the drill. Review of the drill further reflected the following: .2. Locations searched within the facility and any pertinent details for each: Entire facility 3. Time when search of facility grounds was initiated and any pertinent details: Resident was located inside the facility x2 . 6. Location of Resident when found: 1) Education room [ROOM NUMBER]) Private dining room * Describe staff response to drill: Both shifts responded and systematically searched the building unitl the residents were located . Record review of Elopement In-Service, dated 06/05/2023, revealed LVN F and LVN T signed the attendance sheet. The inservice futher reflected: 1. Staff shall promptly report any resident who is trying to leave the premises or is suspected of being missing to the Charge Nurse or Supervisor to evaluate the need for further interventions. 2. If a resident is missing it is a facility-wide emergency. Code [NAME] will be announced. The missing resident procedures will be initiated: A. Determine if the resident is out on an authorized leave or pass. B. If the resident was not authorized to leave, institute a search of the premises. C. If the resident is unaccounted for after a thorough search of the building and grounds, immediately notify: Administrator Director of Nursing Services Residents legal representative or emergency contact Attending physician Law Enforcement Officials D. Provide search teams with resident identification information and begin extensive search of the surrounding territory. 3. When the resident returns to the facility: A. An assessment of the resident will be completed to determine if medical attention is required and provide interventions as indicated. B. Notify search teams that the resident has been located C. The attending Physician and Resident Representative will be notified of the resident's return and the resident status. D. Document relevant information in the resident's medical record. 4. An Elopement/Wandering Evaluation will be completed post elopement incident with follow up documentation for a minimum of 72 hours following the incident. Record review of policy titled Wander System Monitoring Program revised 09/2007, reflected It is the policy of this facility that all new residents will be evaluated with initial assessment process as to whether he or she presents a wondering risk . any resident previously identified as a wandering risk will be reassessed quarterly, and with changes in behavior, all residents identified to be at risk for wondering, will have a wonder monitoring bracelet . Procedures: 1. An initial wondering assessment will be completed on all new residence on admission. See Elopement Risk Assessment. 2. Any resident displaying significant change of status or change of behavior pattern will be reevaluated for potential wondering . Record review of policy titled Elopement/Unsafe Wandering, revised 06/2018, reflected It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement . Procedures: 1. Residents with capabilities of ambulation and/or mobility in wheelchair will have an elopement/wondering evaluation completed to determine risks for elopement and unsafe, wondering on admission, and with observed behaviors of wandering or attempting to elope. 2. Residents with high risk factors identified on an elopement/wondering evaluation are considered at risk and will have an individual individualized care plan developed that includes miserable objectives, and time frames for the care plan interventions will consider the particular elements of the evaluation that put the resident at risk and the observations of wondering behavior .