Health inspection·February 13, 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 record review, interview, and facility policy review the facility failed to ensure Resident #49 did not leave the facility without staff knowledge and did not ensure a safe discharge. This affected one resident (#49) of three residents reviewed for elopement. The facility census was 48. Findings include: Review of the closed medical record for Resident #49 revealed an admission date of 01/23/24 and a discharge date of 02/11/24. Diagnoses included human immunodeficiency virus (HIV), schizophrenia, depression, and dementia. He was his own responsible party. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was moderately cognitively impaired. The assessment identified the resident had no wandering behaviors. The resident required supervision for ambulation. Review of the plan of care dated 01/23/24 revealed no evidence Resident #49 was at risk for elopement. Review of the elopement risk assessment dated [DATE] revealed Resident #49 was not at risk for elopement. Review of the nurses' note dated 02/07/24 at 2:27 P.M. revealed Resident #49 was upset and wanted to go home. Review of the nurse's notes dated 02/10/24 at 5:24 P.M. revealed Resident #49 was not in his room. The facility was searched, and the resident could not be located. The residents' brother was contacted and said Resident #49 was free to leave if he chose to do so. The Director of Nursing (DON) and physician were notified. Review of the nurse's note dated 02/12/24 at 12:27 P.M. revealed Resident #49 left the facility against medical advice (AMA). Interview on 02/12/24 at 9:53 A.M. with Licensed Practical Nurse (LPN) #200 revealed the second floor was not a secured unit. She confirmed Resident #49 was ambulatory and not an elopement risk. Interview on 02/12/24 at 10:31 A.M. with Resident #49's brother confirmed he received a call from the facility on 02/10/24 at approximately 5:00 P.M. informing him the resident was missing. He Page 1 of 2 366021 366021 02/13/2024 Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed he was not surprised, and thought the resident likely returned to his apartment. He confirmed this the following day, 02/11/24 at approximately 11:00 A.M. He revealed both he and his mother had been trying to encourage the resident to stay because they were aware the resident wanted to leave. Interview on 02/13/24 at 11:29 A.M. with Registered Nurse (RN) #203 revealed she began work at 3:16 P.M. on 02/10/24. She did not see Resident #49 at that time, so she started looking for him. When she could not locate him, she called the DON around 5:00 P.M. to notify her she could not locate the resident. Interview on 02/13/24 at 11:42 A.M. with the DON revealed the facility called the resident's brother after they could not locate the resident at the facility. The resident's brother said the resident probably went back to his apartment and not to worry about it. The DON confirmed the police were not contacted and no further investigation was conducted as a result. The DON revealed no interventions were in place to prepare for an unexpected discharge for the resident, despite his discussion of wanting to leave on 02/07/24. She confirmed the facility was aware of the residents' intentions to leave, but did not plan for a potential, unplanned discharge. Interview on 02/13/24 at 11:52 A.M. with LPN #204 confirmed she was assigned to Resident #49 on 02/10/24. She last saw him before she left for the day at approximately 3:00 P.M. or 3:30 P.M. She revealed he was in the common area and did not seem distressed, exit seeking, or confused. Interview on 02/13/24 at 12:24 P.M. with the DON confirmed Resident #49 left without staff knowledge and without his medications. She verified the facility did not complete an investigation to determine how the resident was able to leave the facility without staff knowledge. She revealed his brother picked them up either 02/11/24 or 02/12/24. Interview on 02/13/24 at 1:28 P.M. with Resident #49's brother confirmed he picked up the residents' medications on 02/11/24 and delivered them to the resident around 6:00 P.M. that evening. Review of the facility policy titled Discharge Summary dated February 2023 revealed when the facility anticipated a discharge, a discharge summary would be developed that included a post-discharge plan of care including where the resident planned to reside, arrangements for follow up care and any medical and non-medical services needed and a reconciliation of pre-discharge and post-discharge medications. Review of the facility Wandering and Elopement Policy, dated 08/2021, revealed if a resident is missing, initiate the elopement/missing resident emergency procedure including if the resident is not located, notify the administrator and the DON, the resident's legal representative, the attending physician, and law enforcement officials. The policy also states, complete and file an incident report. This deficiency represents noncompliance investigated under Complaint Number OH00151042. 366021 Page 2 of 2