Health inspection·January 31, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigations, review of hospital documentation, observations, staff interviews, and policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being cognitively impaired and at risk for elopements did not elope from the facility. This resulted in Actual Harm when Resident #04 eloped from the secured memory care unit on 01/23/24 without staff knowledge, and was found outside the facility by a generator. Resident #04 sustained injuries from a fall that occurred during the elopement which required hospital evaluation and treatment for the placement of a suture to a lip laceration and for treatment of a right thigh contusion. This affected one (#04) of three residents reviewed for elopement risk. The census was 84. Findings include: Review of Resident #04's medical record revealed an admission dated 01/10/24. Diagnoses included anxiety disorder, major depressive disorder, iron deficiency anemia, and mental disorder. Resident #04 was admitted for a respite stay. Resident #04 resided in the secured memory care unit on the second floor of the facility. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. Resident #04 was assessed as wandering daily. Review of an Elopement Evaluation dated 01/10/24 revealed Resident #04 was at risk for elopement. Resident #04 scored eight out of a possible nine. Scores above one were at risk for elopement. Review of a Secured Unit Evaluation dated 01/10/24 revealed Resident #04 was approved for admission to the secure unit. Resident #04 was evaluated as habitually wandering and would be able to wander out of the facility and not find their way back. Review of a care plan initiated on 01/10/24 revealed Resident #04 was at risk for wandering and elopement and at for risk for falls and fall related injury. Review of Resident #04's physician orders dated 01/12/24 revealed the resident may reside on secured care unit related to decreased cognitive awareness and safety. Review of progress notes revealed on 01/10/24 Resident #04 was moved from a first-floor room to the secure memory care due to wandering concerns. While on the memory care unit, Resident #04 was Page 1 of 3 365321 365321 01/31/2024 Oaks of West Kettering The 1150 West Dorothy Lane Kettering, OH 45409

F 0689 Level of Harm - Actual harm documented as wandering, exit seeking, and resisting care. On 01/23/24 Resident #04 was documented as being treated after a fall. Resident #04's upper lip was bleeding, and she had a swollen right knee. Resident #04 was sent to the emergency room (ER) per her daughter's request. Further review of the progress notes and medical record revealed there was no documentation of Resident #04's elopement on 01/23/24. Residents Affected - Few Review of the facility's investigation revealed Resident #04 was last seen by staff in the secured memory care unit on 01/23/24 at 7:30 A.M. At 7:40 A.M., memory care staff Licensed Practical Nurse (LPN) #140, State Tested Nursing Assistant (STNA) #130, and STNA #160 were not able to locate Resident #04 so they began searching the secured memory care unit. No exit alarms had sounded. Resident #04 was found outside the back of the facility by Activity Aide (AA) #120 that was entering the building. Resident #04 was standing by the facility trying to exit from inside the chain link fence that surrounded the generator. Resident #04's hair braids got stuck in a metal loop and AA #120 helped free them. AA #120 called for assistance to dietary staff. Dietary Director (DD) #150 met LPN #140 and STNA #130 who were looking for Resident #04 exiting the elevator. Resident #04 was treated for a bleeding lip and right knee injury. Resident #04's daughter and physician were informed. Review of Hospital emergency room (ER) documentation dated 01/23/24 revealed Resident #04 was assessed for post-fall injuries. Resident #04's upper lip had a small laceration of less than five millimeters (mm) that was repaired with one suture. Resident #04 complained of right leg pain. X-rays to the right leg were negative for any acute injury. Resident #04 was diagnosed with right thigh contusion. A magnetic resonance imaging (MRI) scan of Resident #04's head was negative for any acute injury. Resident #04 was admitted to the ER at 12:00 P.M. and discharged at 2:24 P.M. During an interview on 01/31/24 at 10:25 A.M. the Director of Nursing (DON) confirmed Resident #04 eloped from the memory care unit and was found outside the back of the facility on 01/23/24 by AA #120 who was coming into work. No exit alarms had been activated. The DON stated the facility conducted an investigation into the elopement but was unsure how Resident #04 had eloped from the secured memory care unit located on the second floor and exited the facility. Exit alarms were checked by maintenance and were found to all be working correctly. No video surveillance was available. Resident #04's Wanderguard (alarm device to prevent elopement) was checked and was functioning. Observations of Resident #04 in the secured memory care unit on 01/31/24 at 10:55 A.M., 3:01 P.M. and 3:50 P.M. revealed she was confused and unable to be interviewed. A Wanderguard was in place to Resident #04's left ankle. During an interview on 01/31/24 at 11:30 A.M. with AA #120 she stated that she found Resident #04 outside the back of the facility on 01/23/24 when walking from the parking lot. Resident #04 was first seen inside of a chain link fence barrier around the facility's generator. Once AA #120 recognized Resident #04 she opened an entrance door located by the generator and called for dietary staff to help. Dietary Director (DD) #150 responded and went for help. AA #120 walked with Resident #04 and tried to convince her to go back into the facility. Human Resource (HR) #200 and LPN #140 responded and were able to get Resident #04 back into the facility. Resident #04's lip was bleeding, and her pants were ripped. During an interview on 01/31/24 at 12:30 P.M., STNA #130 stated that she was passing out breakfast trays on 01/23/24. STNA #130 stated Resident #04 was standing near the food tray cart. STNA #130 went down the hall to deliver another resident's breakfast tray and when she came back to get another tray, LPN #140 asked if she had seen Resident #04. STNA #130 along with LPN #140 and STNA #160 365321 Page 2 of 3 365321 01/31/2024 Oaks of West Kettering The 1150 West Dorothy Lane Kettering, OH 45409

F 0689 Level of Harm - Actual harm Residents Affected - Few started searching the secured memory care unit for Resident #04. STNA #130 stated Resident #04 was not found in the unit, so STNA #130 and LPN #140 went downstairs to see if therapy staff had come and took her out of the unit. While exiting the elevator, STNA #130 stated DD #150 informed them Resident #04 was found outside back of the facility. STNA #130 went with LPN #140 to get Resident #04 back into the facility. Resident #04's lips were bleeding, and she had a tear on her black jeans. STNA #130 stated no exit alarms had been activated. During a phone interview on 01/31/24 at 2:20 P.M., LPN #140 stated that on 01/23/24 at approximately 7:30 A.M. she observed Resident #04 sitting in the common area talking to another resident. LPN #140 stated on 01/23/24 at approximately 7:40 A.M. Resident #04 was unable to be found and all resident rooms and bathrooms were searched on the secured memory care unit. LPN #140 stated when Resident #04 was unable to found on the secured care unit, LPN #140 and STNA #130 went downstairs on the elevator to see if therapy staff had taken her and not informed them. LPN #140 stated no exit alarms in the memory care unit had been activated. While exiting the elevator, DD #150 approached and informed LPN #140 that Resident #04 was outside the facility with AA #120. LPN #140 stated Resident #04's lip was bleeding, and her jeans were ripped. LPN #140 treated Resident #04's lip and knee. LPN #140 called Resident #04's daughter and her physician. Resident #04 reported to LPN #140 that she fell downstairs chasing a boy. During an interview on 01/31/24 at 2:20 P.M., the Administrator and DON both confirmed Resident #04 had eloped from the secured memory care unit and was found behind the facility on 01/23/24. The Administrator and DON stated the facility conducted an investigation, but it was unable to be determined how Resident #04 eloped from the unit. The Administrator and DON stated there was no video surveillance of the elopement. The Administrator and DON confirmed Resident #04 was treated at the hospital for injuries she sustained from a fall during the elopement. Review of an undated facility policy titled The Oaks of [NAME] Kettering regarding Missing Residents revealed staff shall investigate all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or DON. This deficiency represents non-compliance investigated under Complaint Number OH00150572. 365321 Page 3 of 3