Health inspection·January 10, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Immediate jeopardy to resident health or safety THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on record review, staff interview, review of hospital records, review of camera footage, review of the facility's investigation, observations, review of Weather Underground computerized environmental temperatures website, review of Google Maps, and review of the facility's Guideline for Elopement/Missing Resident policy, the facility failed to follow their policy for responding to door alarms and checking residents after the sounding of a door alarm, to prevent the elopement of a cognitively impaired resident, with a history of attempted elopement and who was assessed to be at risk for elopement from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening injuries, negative health outcomes and/or death, when Resident #11 left the facility through an alarmed door, without staff knowledge, and was found by staff in the Emergency Department (ED) of a local hospital, approximately one-half mile from the facility and across a four-lane road with a speed limit of 35 miles-per-hour, after being brought to the ED by an unknown community member. This affected one (#11) of five (#11, #12, #13, #14, #15) residents reviewed for exit seeking behaviors from the facility. The facility identified five residents with a history of exit seeking, and 15 residents at risk for elopement. The facility census was 52. On 01/08/24 at 1:38 P.M., the Executive Director, the Director of Health Services (DHS), and the Clinical Campus Support Registered Nurse (CCSRN) #500 were notified Immediate Jeopardy began on 12/26/23 at approximately 12:56 P.M. when Resident #11 walked out of the north door of the secured unit causing the door alarm to activate, alerting staff a resident may have exited the building. At 12:57 P.M., Certified Resident Care Associate (CRCA) #101 responded to the door alarm and silenced the alarm without opening the door to check outside, and without conducting a headcount of residents on the secured unit; therefore, not following the facility procedure for responding to an activated door alarm. The facility was unaware Resident #11 was missing until approximately 2:44 P.M. when staff determined that the resident sleeping in Resident #11's bed was not Resident #11. Resident #11 was subsequently discovered approximately two hours and 20 minutes later, at 3:16 P.M. by facility staff at the Emergency Department of a local hospital with abrasions to his left hand, right forehead and left knee. The Immediate Jeopardy was removed, and the deficiency corrected on 12/27/23 when the facility implemented the following corrective actions: • On 12/26/23 at 3:25 P.M., the DHS began educating all staff on the facility elopement and missing Page 1 of 5 366221 366221 01/10/2024 Springview Manor 883 West Spring Street Lima, OH 45805

F 0689 resident policy, and staff response to door alarms. This was completed at 6:20 P.M. Level of Harm - Immediate jeopardy to resident health or safety • On 12/26/23 at 3:30 P.M., Licensed Practical Nurse (LPN) #203 notified Resident #11's primary care physician and the Medical Director of the elopement. Residents Affected - Few • On 12/26/23 at 3:37 P.M., a Wanderguard was placed on Resident #11 by the Assistant Director of Health Services (ADHS) #301. • On 12/26/23, ADHS #301 checked the Wanderguards of all residents in the facility to ensure proper functioning. • On 12/26/23 at 3:46 P.M., the DHS and ADHS #301 audited the records of all residents on the secure unit and of all residents on the non-secured units who had a brief interview for mental status (BIMS) of eight or less, indicating cognitive impairment, for elopement risk. • On 12/26/23 at 4:00 P.M., LPN #203 notified Resident #11's son of the incident. • On 12/26/23 at 5:15 P.M., the Executive Director conducted an elopement drill. The facility began completing elopement drills at random times five days a week for four weeks to ensure staff follow the policy. All findings will be relayed to the campus Quality Assurance Committee for review. • On 12/26/23, the Director of Plant Operations #303 checked all the exit doors to ensure they were functioning properly with alarms activating. • On 01/08/24, the medical records for Resident #12, Resident #13, Resident #14, and Resident #15, identified with exit seeking behaviors, were reviewed with no concerns of elopement identified. • Interviews on 01/08/24 between 11:20 A.M. and 2:14 P.M. with CRCA #101, CRCA #102, CRCA #103, and CRCA #104 revealed staff received education and were knowledgeable about the facility's elopement/missing person policy and procedure. 366221 Page 2 of 5 366221 01/10/2024 Springview Manor 883 West Spring Street Lima, OH 45805

F 0689 • Level of Harm - Immediate jeopardy to resident health or safety Interviews on 01/08/24 between 10:16 A.M. and 3:53 P.M. with LPN #201 and LPN #202 revealed staff received education and were knowledgeable about the facility's elopement/missing person policy and procedure. Residents Affected - Few Findings include: Review of the medical record for Resident #11 revealed an admission date of 03/22/23. Diagnoses included Alzheimer's disease, dementia, and unsteadiness on his feet. Resident #11 resided on the secured unit in the facility beginning 03/25/23. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/15/23, revealed Resident #11 was rarely/never understood with short- and long-term memory problems and severely impaired cognitive skills for daily decision making. Review of a care plan initiated 03/29/23 revealed Resident #11 was at risk for wandering. Interventions included observing wandering patterns and escort away from other residents, providing meaningful leisure activities, and monitoring cognitive functioning. Review of the Elopement Risk Review, completed 05/23/23, revealed Resident #11 was at risk for elopement due to a history of exit seeking and residing on a locked/secure unit. Interventions included observing elopement attempts. Review of a progress note dated 07/02/23 revealed Resident #11 was observed by staff to exit the alarmed north door of the secured unit. Staff maintained visual contact of Resident #11 and caught up with Resident #11 on the sidewalk outside the building. Resident #11 was escorted back inside the facility. Review of a progress note dated 12/26/23 at 3:25 P.M. revealed staff found Resident #11 in the local hospital's ED seated in the waiting room. Staff notified the facility's physician regarding Resident #11's status. The facility's physician advised staff to return Resident #11 to the facility and the physician would assess him later in the day. Resident #11 was observed to have abrased areas to his left hand and right forehead. First aid was given by ED staff prior to facility staff's arrival. Review of a progress note dated 12/26/23 at 4:19 P.M. revealed MDS Nurse #300 was notified of the unknown whereabouts of Resident #11 at 2:44 P.M. A head count was completed on the secured unit and all rooms were checked. Resident #11 was unable to be located. The DHS was notified at 2:50 P.M., a facility head count was completed, and the grounds were observed for Resident #11. The elopement protocol was initiated. A phone call was received at 3:15 P.M. from the local hospital stating Resident #11 was in their ED. Resident #11 was returned without incident. Review of a progress note dated 12/26/23 at 4:20 P.M. revealed a skin sweep was completed on Resident #11 and he was found to have abrasions to his left hand and superficial abrasions to his right forehead and left knee. Review of the hospital records dated 12/26/23, revealed Resident #11 was admitted at 2:23 P.M. Resident #11 arrived via walk-in. Arrival complaint revealed Resident #11 was found face down. Resident #11 complained of left-hand pain, stating he tripped earlier and landed on it. Resident #11 had some 366221 Page 3 of 5 366221 01/10/2024 Springview Manor 883 West Spring Street Lima, OH 45805

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few abrasion noted to his palm. Resident #11 was alert with stable vital signs. A left-hand x-ray was completed on 12/26/23 at 2:56 P.M. No fracture or dislocation was identified. Review of the facility investigation of the incident revealed a witness statement from CRCA #101 which revealed CRCA #102 directed CRCA #101 to turn off the door alarm. CRCA #101's statement revealed she did not check outside the door or complete a resident headcount. Review of the witness statement for CRCA #102 revealed she heard the north door alarming but did not look to see if someone was trying to enter the building. Review of the facility investigation revealed staff did not follow protocol when responding to the door alarm on 12/26/23. Interview on 01/08/24 at 11:04 A.M. with the Executive Director and the DHS revealed the DHS was at the facility on 12/26/23 and was notified Resident #11 was missing at 2:50 P.M. The DHS initiated an internal and external search for Resident #11, including sending staff out on foot and in vehicles to look for Resident #11. One staff walked to the ED at the local hospital and found Resident #11 sitting in the waiting room at 3:16 P.M. Further interview revealed Resident #11 had a suspected, unobserved fall between the facility and the ED. Interview on 01/08/24 at 2:05 P.M. with CRCA #101 revealed she worked on the secured unit on 12/26/23 at the time of Resident #11's elopement. She recalled the north door alarm sounding. CRCA #101 silenced the alarm without opening the door and checking outside, and without completing a head count on the secured unit. Interview on 01/08/24 at 2:14 P.M. with CRCA #102 revealed she worked on the secured unit on 12/26/23 at the time of Resident #11's elopement. CRCA #102 stated she was not the staff who responded to the door. Interview on 01/08/24 at 4:29 P.M. with LPN #203 revealed she picked up Resident #11 from the ED on 12/26/23. LPN #203 stated she talked with the receptionist at the ED who stated a Good Samaritan brought Resident #11 to the ED. LPN #203 stated she had no additional information regarding the Good Samaritan and how or where that person found Resident #11. LPN #203 stated she assessed Resident #11's injuries upon return to the facility and found abrasions to his left hand, and superficial abrasions to his right forehead and left knee. Review of the camera footage on 01/09/24 at 9:34 A.M. from 12/26/23 revealed Resident #11 approached the north door at 12:56 P.M. Resident #11 was wearing black shoes, jeans, a hooded sweatshirt and a baseball cap. Resident #11 held down the push bar and placed his foot against the base of the door. Resident #11 then released the door and turned around to face the open hallway. Resident #11 exited the facility at 12:57:38 P.M. The window in the north door was treated with a film allowing light to pass through but clear observation was not possible. A shadow was observed through the window on the left side of the door at 12:57:42 P.M. No additional shadow was observed. The video footage shows CRCA #101 approached the door, pulled the door handle closed, and silenced the alarm at 12:58:03 P.M. CRCA #101 did not open the door or look outside. Review of Google Maps revealed the facility was approximately one-half mile from the ED where Resident #11 was found. The route included crossing a four-lane road. Observation on 01/09/24 at 8:30 A.M. revealed the speed limit in front of the hospital varied from 35 miles per hour to 25 miles per hour. 366221 Page 4 of 5 366221 01/10/2024 Springview Manor 883 West Spring Street Lima, OH 45805

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the Weather Underground computerized environmental temperatures on 12/26/23 between 12:53 P.M. and 3:49 P.M. was 55 degrees Fahrenheit and clear. Review of the policy titled Guideline for Elopement/Missing Resident, revised 05/01/17, revealed staff should respond promptly to a sounding door alarm. The charge nurse, facility supervisor or Executive Director should call staff to a central area and designate the following: 1) a staff person to perform a facility head count to determine who may be missing, and 2) two additional staff members to exit the alarming doorway and go in opposite directions around the building perimeter until they meet each other and return to the central area of the facility. This is non-compliance found during the investigation of Complaint Number OH00149625. 366221 Page 5 of 5