Health inspection·November 21, 2023

F689 Free of Accident Hazards/Supervision/Devises Section 483.25(d) Accidents. The facility must ensure that - Section 483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and Section 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 8/24/23 at 12:30 p.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding a resident elopement from the facility. The department determined the facility failed to provide the necessary supervision Resident 1 required to ensure his safety when Resident 1 eloped from the facility's Behavior Intervention Monitoring Program Room (BIMP, a program designed to provide supervision of specific behaviors which are based on an evaluation from a psychiatrist). This failure resulted in Resident 1's elopement and increased the potential for physical injury and psychosocial harm to Resident 1 during his unsupervised time away from the facility. A review of an admission record indicated Resident 1 was admitted to the facility in April 2023 with diagnoses which included dementia (a loss of memory and problem-solving abilities which interfere with daily life), generalized muscle weakness, difficulty walking, and a lack of coordination. This admission record also indicated Resident 1 was not his own Responsible Party (RP). A review of Resident 1's discharge paperwork upon admission to the facility from the hospital included a history and physical note from the hospital, dated 2/12/23, which indicated, "[Resident 1] brought in by ambulance status post assault...Resident has a [history] of dementia and [RP] provides some of the history. She states that he is not well and wanders the streets..." This discharge paperwork also included a social service note from a previous facility, dated 4/12/23 at 11:23 a.m., which indicated, "Phone call from [Resident 1's RP]...She had a very hard time redirecting [Resident 1] as well. She is adamant that he needs to be in a LTC [long-term care] secured facility for his safety..." A review of an order summary report, printed on 10/13/23 at 1:11 p.m., indicated Resident 1 had the following physician's orders: "[Resident] does not have capacity to make decisions related to...dementia [which started on] 4/13/23..." and, "Monitor aggressive behavior every shift...[which started on] 4/29/23..." A review of a wandering risk observation assessment with an effective date of 4/13/23 at 9:15 p.m. indicated Resident 1 was at risk to wander. A review of a wandering risk observation assessment with an effective date of 4/18/23 at 3:03 p.m. indicated Resident 1 was at a high risk to wander. A review of the admission Minimal Data Set (MDS, an assessment tool) dated 4/19/23 indicated Resident 1 exhibited the following behaviors during a seven-day assessment period: verbal behavioral symptoms (threatening, screaming, or cursing at others) for four to six days; placed others at significant risk for injury, and wandered for four to six days. The MDS also indicated Resident 1 was able to function with supervision, was currently using tobacco, and was expected to remain in the facility. A review of the facility's SBAR (Situation, Background, Appearance, and Review) Communication Form dated 8/22/23 indicated, "[Resident 1] was not seen in the facility by the staff around 6 pm [sic]. Prior to the incident, [resident] was at the gazebo for his smoke brake [sic]." In an interview on 8/23/23 at 12:30 p.m. at the facility, the Director of Nursing (DON) stated Resident 1 had a history of elopement and on 6/22/23 Resident 1 had eloped from his family during a physician's ordered leave of absence from the facility. The DON explained staff usually walked the front and back of the facility to monitor residents, but at the time Resident 1 had gone missing, staff had gone to dinner or were feeding residents who needed assistance to eat their meal. The DON stated no staff witnessed Resident 1 elope, but a table was found placed against the fence which staff assumed Resident 1 used to climb over the fence. The DON also stated Resident 1 had been assigned to the Behavior Room (BR, a room which residents with behaviors are placed to be closely supervised) due to his exit-seeking behavior. In a telephone interview on 8/25/23 at 10:42 a.m., the Certified Nurse Assistant 1 (CNA 1) confirmed she worked at the facility on 8/22/23. The CNA 1 stated she had been assigned to monitor residents who smoked during the smoke break which was scheduled between 6:30 p.m. and 7 p.m. The CNA 1 was aware Resident 1 smoked and had last observed him at approximately 6 p.m. The CNA 1 stated when she started to gather everyone to go to the smoking area, she was unable to find Resident 1. In a telephone interview on 8/25/23 at 10:57 a.m., the Resident Safety Monitor 1 (PSM1) confirmed he had been assigned to monitor residents in the BR on 8/22/23. The PSM 1 stated residents in the BR were supposed to sign in and out of the room upon entry and exit. The PSM 1 stated he was aware Resident 1 smoked and was expected to go to the smoking patio during the scheduled smoke break from 6:30 p.m. to 7 p.m. The PSM 1 stated Resident 1 signed out of the BR at 5:53 p.m. In a telephone interview on 8/25/23 at 11:30 a.m., the Nurse Supervisor (NS) confirmed she had worked at the facility on 8/22/23. The NS stated at approximately 5:30 p.m. to 6 p.m. staff had reported Resident 1 was missing. The NS stated she immediately called a Code Purple (a code used to notify staff a resident was missing). The NS stated when she arrived at the back patio to search the area, she observed a table along the fence which was not supposed to be there. A review of the facility's policy titled "Safety and Supervision of [Residents]", revised December 2007, indicated, "...[Resident] safety and supervision and assistance to prevent accidents are facility-wide priorities...Our [resident]-oriented approach to safety addresses safety and accident hazards for individual [residents]...Staff shall use various sources to identify risk factors for [residents], including the information obtained from the medical history, physical exam, observation of the [resident], and the MDS...[Resident] supervision is a core component of the systems approach to safety. The type and frequency of [resident] supervision is determined by the individual [resident]'s assessed needs and identified hazards in the environment...The type and frequency of [resident] supervision may vary among [residents] and over time for the same [resident]..." A review of the facility's policy titled "Elopements", revised December 2007, indicated, "...If an employee observes a [resident] leaving the premises, he/she should...Attempt to prevent the departure in a courteous manner...Get help from other staff members in the immediate vicinity...and Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a [resident] has left the premises." Therefore, the department determined the facility failed to provide the necessary supervision Resident 1 required to ensure his safety when Resident 1 eloped from the facility's Behavior Intervention Monitoring Program Room. This failure resulted in Resident 1's elopement and increased the potential for physical injury and psychosocial harm to Resident 1 during his unsupervised time away from the facility. This violation occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a resident.