Health inspection·January 4, 2024

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 medical record review, staff interview, and review of the facility policy the facility failed to provide care and supervision to prevent residents from eloping from the facility. This affected one (Resident #10) of ten facility-identified residents at risk for elopement. The facility census was 202. Findings Include: Review of the medical record for Resident #10 revealed an admission date of 12/20/23 with diagnoses including metabolic encephalopathy, type two diabetes, hypertension, and chronic kidney disease. Resident #10 was discharged to the hospital on [DATE] following an elopement from the facility. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 12/20/23 revealed resident was cognitively impaired. Review of the preadmission hospital records for Resident #10 dated 11/27/23 revealed resident was diagnosed with acute encephalopathy, possible multi-infarct dementia and metabolic encephalopathy from hypoglycemia. Further review of the hospital records revealed Resident #10's family reported to the hospital staff that he had exhibited wandering behavior prior to the hospital admission. Review of the admission nurses' note for Resident #10 dated 12/20/23 revealed the resident was admitted to the facility for physical therapy and occupational therapy and was alert to his name only. Review of the elopement risk assessment for Resident #10 completed on 12/20/23 revealed the resident was assessed for elopement risk and received a score of nine which indicated he was not at risk for elopement. Review of the care plan for Resident #10 dated 12/24/23 revealed it did not include interventions for wandering or elopement prevention. Review of the elopement risk assessment for Resident #10 completed on 12/26/23 revealed a score of 13 which indicated Resident #10 was at high risk for elopement. Review of physician orders for Resident #10 revealed an order dated 12/26/23 to place a Wanderguard bracelet (a device to alert the staff if the resident elopes from the facility) on the resident. Review of the nurses' note for Resident #10 dated 12/26/23 revealed the resident expressed a desire to leave the facility. Licensed Practical Nurse (LPN) #100 told Resident #10 to stay close to her Page 1 of 3 365379 365379 01/04/2024 The Laurels of Walden Park 5700 Karl Road Columbus, OH 43229

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and she would call his sister. Resident #10 walked away from LPN #100 towards an emergency exit door and tried to leave. LPN #100 was able to persuade Resident #10 to walk back to his room. LPN #100 assigned a State Tested Nursing Assistant (STNA) to provide one-to-one supervision for Resident #10 until he calmed down. On 12/26/23 at 5:00 P.M. the one-to one supervision was discontinued. Review of the elopement investigation dated 12/27/23 revealed Resident #10 had refused medications on 12/26/23 and 12/27/23 and was last seen in the facility in his bed on 12/27/23 at 2:00 A.M. by LPN #130. At approximately 3:00 A.M. on 12/27/23 LPN #130 was making rounds and noticed the Resident #10 was not in his bed or his bathroom. LPN #130 notified other staff that Resident #10 was missing, and the staff began to search for him. LPN #130 noted the window to the room across from Resident #10's room (Resident #12's room) faced the parking lot and was wide open. The facility notified local police on 12/27/23 at 3:50 A.M. that Resident #10 was missing. Local police found the resident at a bus stop near the facility on 12/27/23 and took the resident to the hospital for an evaluation. Review of the preliminary police investigation report dated 12/27/23 revealed the facility called the police on 12/27/23 at 3:58 A.M. and notified them Resident #10 was missing from the facility and they suspected he exited the building via a bedroom window. Review of the written statements from Registered Nurse (RN) #135, LPN #130 and STNA #140 who worked from 7:00 P. M. on 12/26/23 to 7:00 A. M. on 12/27/23 revealed they began to search for Resident #10 on 12/27/23 at 3:00 A.M. once they were advised he was missing. Each staff member participated in the search and all residents were accounted for except for Resident #10 Review of the hospital emergency report for Resident #10 dated 12/27/23 timed at 9:59 A. M. revealed the resident was found outside the facility wandering and unable to answer questions and had been transported to the emergency room by ambulance. Police confirmed Resident #10 was a missing person who had escaped from the facility. Resident #10 was alert and oriented to person only and was examined by the hospital physician with no injuries. Resident #10's vital signs were stable, and all lab tests and x-rays were within normal limits. Interview on 01/02/24 at 1:00 P. M. with LPN #100 confirmed she worked from 7:00 A.M. to 7:00 P.M. on 12/26/23. LPN #100 confirmed Resident #10 told her early in the shift that he wanted to leave, and she requested he stay with her while she finished passing the medications and then she would call his sister. Resident #10 then walked away towards an emergency exit door and tried to go out the door. LPN #100 followed him towards the door and was able to redirect him back to his room. LPN #100 confirmed she notified the nurse practitioner (NP) of Resident #10's exit seeking behavior and the NP gave an order for a Wanderguard bracelet. LPN #100 confirmed she attempted to place the Wanderguard bracelet on Resident #10 without success. She then assigned STNA #150 to provide one-to-one supervision to the resident until he calmed down. LPN #100 confirmed the one-to-one supervision was discontinued on 12/26/23 at 5:00 P.M. because the resident was no longer displaying agitation and restlessness. LPN #100 confirmed Resident #10 was in his room on 12/26/23 at 7:00 P.M. when she ended her shift. Interview on 1/02/24 at 1:15 P. M. with STNA #150 confirmed she sat with Resident #10 on 12/26/23 from 9:00 A. M. until 5:00 P. M. until he was calm. Interview on 01/04/24 at 9:10 A. M. with Occupational Therapist (OT) #114 and OT #116 confirmed they worked with Resident #10 when he was admitted to the facility from 12/20/23 to 12/25/23. They described Resident #10 as very confused and unable to comprehend simple requests. 365379 Page 2 of 3 365379 01/04/2024 The Laurels of Walden Park 5700 Karl Road Columbus, OH 43229

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/02/23 at 2:59 P. M. with the Director of Nursing (DON) confirmed the facility had a secured unit, but Resident #10 was not placed in the unit because he did not have a diagnosis of dementia. The DON further confirmed Resident #10 had an exit-seeking attempt on 12/26/23 and the facility completed a new elopement risk assessment which indicated he was at risk for elopement. The DON confirmed the order for the Wanderguard bracelet for Resident #10 was not implemented because the resident refused. The DON confirmed the facility did not develop an elopement risk care plan for Resident #10, and the resident eloped from the facility on 12/27/23. Review of facility policy titled Elopement Policy dated 04/26/22 revealed the facility would attempt to prevent resident elopements to the extent possible. Elopement occurred when a guest/resident who needed supervision left a safe area without authorization and/or any necessary supervision to do so. This deficiency represents non-compliance investigated under Complaint Number OH00149516. 365379 Page 3 of 3