Health inspection·June 2, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 interview, observation, and record review the facility failed to provide appropriate supervision to prevent an elopement, which resulted in a missing resident, and failed to notify 911 in a timely manner of the missing resident for 1 of 3 sampled elopement risk residents of 7 elopement risk residents in the facility (Resident #1). The deficient practice allowed Resident #1 to exit the facility undetected on [DATE] at 4:47AM and walk approximately 2 miles with bare feet. Resident #1 was found by the police and was transported by Emergency Services to a local hospital for evaluation. There were 109 residents in the facility at the time of the survey. The facility's Administrator was notified of Immediate Jeopardy on [DATE] at 4:54 PM. The findings included: The policy titled Missing Resident, implementation date of [DATE], under the heading Procedure, stated: 1. All personnel are responsible for reporting a resident attempting to leave the premises or suspected missing to the Charge Nurse or Director of Nursing as soon as practical. This includes any resident that did not sign out on a pass and/or did not notify a staff member of his or her leaving. Resident #1 was admitted to the facility on [DATE]. Resident #1's Quarterly Minimum Dataset (MDS) assessment, dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicates a severe cognitive impairment. The resident had the following pertinent diagnoses: Metabolic Encephalopathy, Psychotic disorder with hallucinations due to known physiological condition, Unsteadiness on Feet, Cognitive Communication Deficit, Unspecified Dementia, Unspecified Severity, With Agitation, and Cortical Age-Related Cataract, Right Eye. These diagnoses contribute to the resident's inability to make appropriate decisions regarding his own safety and wellbeing. The cataract could have contributed to his vulnerability by decreasing his vision and depth perception, which could have led to falls and poor judgement regarding dangers such as distance and speed of approaching traffic. At approximately 4:30 AM on [DATE], Resident #1 left his room, exited the facility into a fenced patio area with large shrubs lining the inside perimeter of the fence, through a door that was unlocked and unalarmed. Video surveillance cameras caught the resident searching for a way to get out of the fenced space. The resident was seen, by camera, going into the shrubs several times until he found Page 1 of 3 105659 105659 06/02/2023 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few an opening that allowed him to climb the 4-foot fence. Once over the fence, the cameras recorded the resident walking off the facility's property on the sidewalk heading west. The resident was bare foot at the time of the incident. The video surveillance recording put the time that the resident left the premises at 4:47 AM. The resident walked approximately 2 miles heading west along a residential street with a speed limit of 25 mph. Approximately 1 large block prior to the street's terminus there is a railroad crossing with a pair of tracks, one heading north and the second heading south. The street terminates at a curved north-south road that parallels a park with a large lake. There is easy access to the park with a path that leads directly to the lake. The resident proceeded south on the road until the road intersected with an east-west 4 lane road, with a 45-mph speed limit, near the northbound entrance ramp to a major north-south highway, with a speed limit of 70 mph, where he was found by the police at approximately 9:40 AM, according to the police report. The resident was off facility property on his own for approximately 5 hours. On [DATE] the weather at 4:47 AM was partly cloudy with a temperature between 71- and 72-degrees Fahrenheit (F). At 9:40 AM, the approximate time the resident was located by the police, the weather was scattered clouds with a temperature between 81- and 82-degrees F. After being found by police, the resident was transported to a local hospital for evaluation, and then returned to the facility. Upon his return to the facility, Resident #1 was reassessed for his BIMS score and was found to have a reduction to a 3 out of 15. This indicated Resident #1 was more severely cognitively impaired than his prior assessment had indicated on [DATE]. While out of the facility, Resident #1 could have gotten lost, struck by a train or car and been severely injured or died, walked to the lake fallen in and drowned, or because of his bare feet, he could have suffered an injury that could have become severely infected leading to the loss of a limb. On [DATE] at 2:33 PM, an interview was conducted with Resident #1 regarding the incident. Resident #1's thought processes were disjointed. Resident #1 did remember going out of the building and out into the patio area. He remembered, with prompting, climbing the fence. When asked about being barefoot Resident #1 stated that he didn't have these, indicating his slippers. Resident #1 did not remember where he went but indicated that he walked a long way. On [DATE] at 2:55 PM, an interview was conducted with Staff A, a Registered Nurse (RN). Staff A stated that she started her shift by reviewing her assignment and organizing her care. She stated that she checked Resident #1's vital signs at around 1:15 AM. Staff A stated Resident #1 was watching TV at that time. Staff A stated she saw Resident #1 between 4:00 AM and 4:30 AM. Staff A indicated her Certified Nursing Assistant (CNA) notified her Resident #1 was missing after 6:00 AM. Staff A instructed the CNA to look in the bathroom and when Resident #1 was not found she and the CNA did a room to room search for the resident. Staff A stated it took about a half-hour to search the first floor then the nurse went to the second floor where she and the second-floor staff searched for Resident #1. When Resident #1 was not found they expanded the search to around the building and in the community. Staff A stated that another nurse took her car and headed east, Staff A took her car and headed west. Staff A stated she took an auxiliary staff member with her to search. Once Staff A returned from looking for the resident then she called the Director of Nursing (DON) to report Resident #1 was missing. Staff A stated that no alarms went off. Staff A stated that at the time of the event she did not think about calling the DON sooner than she did. Staff A stated that the facility re-educated the staff on the different protocols to follow but the facility had not yet conducted drills. On [DATE] at 3:41 PM, a telephone interview was conducted with Staff B, Certified Nursing Assistant (CNA). Staff B stated that at 1:00 AM on [DATE], she made rounds, and all residents were sleeping. Staff B explained that at 3:00 AM she made rounds and noted all of the residents were sleeping. Staff B stated that at 5:00 AM she 105659 Page 2 of 3 105659 06/02/2023 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few started her morning rounds which included changing the residents and assisting with morning care. Staff B stated that at approximately 6:00 AM, Staff B went to do morning care for Resident #1, and he was missing. Staff B stated she checked the bathroom and when she did not see Resident #1, she told the nurse. Staff B stated that the nurse informed the other staff and then the nurse and Staff B started checking every room for Resident #1. On [DATE] at 11:00 AM, an interview was conducted with the Director of Nursing (DON) regarding the elopement policy. The DON admitted that when she was notified of the elopement she panicked. The DON explained that by the time the police were contacted regarding the missing resident, the police had already found the resident and informed the DON that he was being transported to the hospital to make sure there was no negative outcomes for the resident, especially since it was warm outside, between 81-82 F, and Resident #1 was bare foot. 105659 Page 3 of 3