Health inspection·September 29, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the facility failed to ensure all residents were supervised to prevent elopement from the facility for 1 of 2 residents reviewed for elopement (Resident #2). The findings included: A review of the facility policy titled Nursing - Elopement Prevention defines an elopement as, Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A review of Resident #2's record revealed the resident was admitted to the facility on [DATE] after being struck on his bicycle by a motor vehicle resulting in several traumatic injuries including facial fractures, rib fractures, respiratory injuries requiring a tracheostomy (trach) placement for ventilator assisted breathing and a feeding tube for nutrition due to dysphagia (difficulty swallowing). The resident was placed in this facility for rehabilitation purposes after being stabilized at the hospital and the trach being removed. A review of the resident's Brief Interview for Mental Status (BIMS) revealed on the 5-day admission assessment dated [DATE], the resident received a score of 0 due to him not being understood and not answering the questions. The staff assessment for mental health portion of the MDS was completed and revealed the resident has short term and long-term memory problems and his cognitive skills for daily decision making was severely impaired (never/rarely made decisions). The resident did not have any behaviors including wandering behaviors. The resident was dependent on a wheelchair for mobility in the facility. The resident was seen on 05/18/23 by psychiatric services and deemed incapacitated. The nursing assessment on admission on [DATE] revealed the resident is confused but not an elopement risk. A repeat elopement risk completed on 06/15/23 indicated no elopement risk. A review of the BIMS completed on 08/15/23 (a 5-day admission assessment) post elopement indicated a BIMS of 2, which suggests severe cognitive impairment. A review of Resident #2's care plans revealed a care plan in place for impaired cognitive function or impaired thought processed related to head injury with an intervention of cue, reorient, and supervise as needed. An interview with the speech/language pathologist (SLP) on 09/29/23 at 10:15 AM revealed she was the staff member who completed the cognitive assessments in the facility and did complete the assessments for Resident #2. The SLP stated the resident had a difficult time talking and swallowing because Page 1 of 3 105492 105492 09/29/2023 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few he previously had a tracheostomy and was just decannulated (trach removed) prior to arriving at this facility. She was asked about his low MDS BIMS score of 0 on 05/17/23 and BIMS score of 2 on 08/15/23. She stated he received those scores because he was unable to talk on admission and refused to answer her at other times. She stated the BIM scores only measure memory and orientation. On 08/11/23 the SLP stated she attempted to do the SLUMS (St. Louis University Mental Status Exam) assessment on him, and he told her to go away and wheeled himself away. She stated she would just give him cognitive tasks to do, and the resident was able to make his needs known. The SLP did not believe the BIMS scores are accurate for this resident due to him being uncooperative during the tests. A review of adverse incident log revealed Resident #2 eloped from the facility on 08/05/23. An adverse incident report was made to the State and an Immediate and 5-day Federal report was completed. There was no mention of how the resident exited the facility in the reports reviewed. A review of the elopement investigation revealed Resident #2 was able to propel himself in the wheelchair and had never made any attempts to exit the facility. The resident received his medication from Staff B, a registered nurse (RN), at approximately 6:00 PM. The resident's meal had been served to him at approximately 5:30 PM and the resident had stated to Staff A, a certified nursing assistant (CNA), that he would eat when he was ready. The resident was observed in the lobby sitting with his headphones on listening to his cell phone. At approximately 6:30 - 6:45 PM Staff A was cleaning up used trays from residents' room and noticed Resident #2's meal was untouched. At that time the resident was not in his room and the nursing staff initiated the missing person protocol and began a search for the resident. At 6:50 PM the physician, Director of Nursing (DON) and family were notified. Staff A went to the gated patio and saw the wheelchair the resident was using, but the resident was not on the patio. Some of the staff drove to search for the resident since he was not located in the facility or the grounds. At 7:45 PM the resident was located by Staff C, a CNA, at a bus stop approximately a mile from the facility. The resident was transported back to the facility by Staff C and the resident refused to go back inside and stated he wanted to leave. The resident's physician wrote an order to transfer to the ED for evaluation and the resident was admitted under the [NAME] Act. On 09/29/23 at approximately 8:50 AM a tour of the outside patio was conducted with the Director of Maintenance and the Administrator. It was explained how they believe the resident was able to elope from the facility. The resident's patio is surrounded by a grassy area and beyond this area is a 6-foot wooden fence. On the evening of the elopement an area of the fence had been broken down (video/photo evidence obtained). The staff believe Resident #2 kicked a hole in the fence large enough to get through and left the faciity on foot. The area of the fence with the hole was located about 5 feet from the building where the [NAME] hallway is located. There are windows in each resident's room facing into the grassy area inside the fence. It would have been light at the time of day the hole was put in the fence, but the resident was able to leave the property unnoticed by any staff. The area in the fence was immediately repaired by Staff D, a maintenance worker, when noted on the evening of the elopement. The fence was checked for weak areas by the surveyors. The fence was noted to have some areas where the wood had rotted, possibly due to wet weather. The fence had approximately 4 loose boards that needed to be reattached. The area that was pointed out as being where there had been a hole in the fence was leaning to the outside (photo evidence obtained) but was standing and not able to be pushed down by the surveyors. There is no mention of the resident leaving the facility through a hole kicked in the fence in the adverse report or the Federal reports. It was noted the patio area did not have any type of surveillance cameras. The administrator stated the patio is for the residents and not all the residents require supervision while outside on the patio since it is a secure area. The 105492 Page 2 of 3 105492 09/29/2023 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0689 gate leading to the outside of the area is locked and requires a code to get out and it is alarmed. Level of Harm - Minimal harm or potential for actual harm In an interview with the Director of Rehabilitation (DOR) on 09/29/23 at approximately 10:15 AM it was revealed that Resident #2 would only do whatever he wanted to do. Documentation reviewed that he would refuse therapy. She stated when he eloped on 08/05/23 he walked a mile however he would not walk more than 30 ft in the rehab sessions. He stated he just wanted to be out of the facility. She also stated Resident #2 would only show them what he wanted the facility to know. The DOR believed it was possible for Resident #2 to walk a mile to get to the bus stop and that he was capable of more than what he was doing in the facility. Residents Affected - Few Interviews were conducted with all the staff involved with the care of Resident #2 on the evening of the elopement. Staff A was Resident #2's CNA that evening and had provided him with his dinner. On 09/26/23 at 9:40 AM, Staff A was contacted by phone. She stated she saw the resident when she was making her rounds talking on the phone in the lobby. She stated that 20 minutes later he was still on the phone when she told him his dinner tray was in his room. The resident acknowledged her when informing him of the dinner tray being present in his room. She told him she just didn't want his dinner to get cold. She stated she then went to assist another resident to eat and after started to gather the dinner trays up and realized Resident #2 had not eaten his dinner. Staff A stated she then started to look for him. She went to the lobby the tv room all the floors and she went to the patio. She stated she saw a wheelchair in the patio however she couldn't identify the wheelchair as the missing resident's chair. She stated she did not notice the hole in the fence at that time. She stated she immediately went to the nurse and told her this was serious. The entire facility started to look for the resident. On 09/29/23 at 9:25 AM Staff B was interviewed by phone. She was the nurse who was assigned to Resident #2 and stated on the day the resident eloped she saw him at 6:00 PM when she administered medications. She stated he was in his wheelchair. She stated she was not aware the resident was missing until the CNA notified her the resident had not eaten his dinner tray. She stated the CNA stated she could not find him anywhere. On 09/29/23 at 12:13 PM Staff C was interviewed via phone. Staff C was the CNA who found Resident #2. She stated she left in her car and found Resident #2 at the bus stop. She stated she asked him what was going on and he stated he wanted to go to the bank, and he did not want to go back to the facility. She was able to get him in her car and she took him back to the facility and then he would not get out of the car. She had the DON talk to Resident #2 and persuade him to get out of the car. Her official statement stated she found the resident at approximately 7:30 PM. The above was reviewed with administration on 09/29/23 at approximately 12:30 PM. 105492 Page 3 of 3