Health inspection·March 12, 2021

F689 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 72523(a) Patient Care Policies and Procedures – Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/15/2021, the Department of Public Health (DPH) received a facility reported incident (FRI) that a resident (Resident A) eloped (leaving without permission unsupervised) from the facility on 1/14/2021, at 3 a.m., and was found on the same day at 10:15 p.m., at the beach. On 1/16/2021, at 3:30 p.m., an unannounced visit was made to investigate the FRI. The facility failed to: 1. Ensure Resident A was adequately supervised on a locked unit, the locked unit was secured, alarms activated, and residents were closely supervised to prevent an elopement from occurring. 2. Follow their policy and procedure that stipulated, residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents. As a result, Resident A, who had a behavior of walking and pushing on doors was not being supervised, went missing from the locked unit of the facility on 1/14/2021 in the middle of the night, for over 20 hours. Resident A was found five miles away from the facility at the beach and brought back to the facility by police officers. During a review of Resident A’s Admission Records (Face Sheet) the Face Sheet indicated Resident A, was a 75 year-old male, who was initially admitted to the facility on 10/19/2018 and last readmitted to the facility on 10/5/2020. Resident A’s diagnoses included insomnia (difficulty falling and/or staying asleep), Parkinson’s disease (a progressive disorder affecting movement often including shaking and stiffness), and schizophrenia (a serious mental disorder in which a person interprets reality abnormally). During a review of Resident A’s Minimum Data Set (MDS), an assessment and care screening tool, dated 1/12/2021, the MDS indicated Resident A’s cognitive (thought process) skills for daily decision-making were moderately impaired. The MDS indicated Resident A required an extensive one-person physical assist to walk in his room, the corridors/unit and to complete his activities of daily living ([ADLS] task such as eating, bathing, dressing, grooming and toileting). According to the MDS, Resident A’s balance while moving from a seated to standing position, walking and turning around was not steady. During a review of Resident A’s Wandering/Elopement Risk Assessment, dated 10/5/2020, the assessment indicated Resident A was at risk for wandering/elopement. The staff’s interventions included frequent monitoring. During a review of Resident A’s Fall Risk Assessment, dated 1/5/2021, the assessment indicated Resident A had a score of 17. A total score of 10 or above represented a high risk for falls. During a review of Resident A’s care plan, dated 10/5/2020, the care plan indicated Resident A was at risk for elopement as evidenced by episodes of confusion. There was no goal identified on the care plan. The staff’s approaches included to monitor Resident A for “tailgating” (the resident would follow closely behind a person) when visitors are in the building. During a review of Resident A’s Nurse’s Note, dated 1/14/2021 and timed at 5 a.m., the Nurse’s Note indicated at 11:10 p.m. on 1/13/2021, the resident (Resident A) was noted walking near Station A. The Nurse’s Note indicated at 1 a.m. on 1/14/2021, the resident was noted walking in the hallway near his room. The Nurse’s Note indicated a certified nursing assistant (CNA) observed the resident (Resident A) sleeping in his room at 2 a.m. (1/14/2021). At 3 a.m., the same morning, during rounds a Licensed Vocational Nurse (LVN 2) noted Resident A was not in his room or in the hallway. The Nurse’s Note indicated the staff searched the rooms, closets, bathrooms, outside the building, and the vicinity surrounding the facility and Resident A was not found. The Nurse’s Notes indicated the local police department was notified of the resident missing. During a review of Resident A’s Nurse’s Note, dated 1/14/2021 and timed at 11 p.m., the Nurse’s Note indicated the local police department called the facility and reported Resident A had been found. According to the note, Resident A returned to the facility with dry, calloused (hardened skin) feet due to only wearing socks but was unharmed. During an interview with LVN 1, on 1/16/2021 at 3:58 p.m., LVN 1 stated Resident A was alert to name, but was very delusional (believing things that are not true) and he ambulated (walked) and liked to hide in other resident’s rooms, closets, and dark places and had a behavior of pushing on the doors. During an observation, on 1/16/2021 at 4:10 p.m., all three doors in the facility were inspected. All alarms on the three doors were activated following application of pressure on the door handles. The alarm would sound and became progressively louder, and after approximately 30 seconds the door would unlatch allowing it to be pushed open. During an interview with the Director of Nurses (DON), on 1/16/2021 at 4:20 p.m., the DON stated she was called by facility’s staff between the hours of 3:30 a.m. and 4 a.m., on 1/14/2021. The DON stated staff reported to her Resident A was last seen at 2 a.m., and had eloped from the facility. The DON stated staff searched the interior and exterior of the building, the premises outside, and the local community, but could not find Resident A. The DON stated it was determined Resident A left from the facility’s side door that was left unlatched and ajar. The DON stated on 1/14/21, the police found Resident A on the beach and brought him back to the facility and the resident was wearing a shirt, sweatpants, and a hospital gown. During an observation, on 1/16/2021 at 5:40 p.m., Resident A was in his room lying in bed. Resident A was alert and oriented to name only and very confused. Resident A stated he had not gone to the beach and denied leaving the facility. During a review of the local weather forecast for 1/14/2021, the forecast indicated the weather in the area, the beach, where Resident A eloped, was 52 degrees Fahrenheit ([F] measurement of temperature) that night and 57 F during the day. During a telephone interview, on 1/27/2021 at 11:07 a.m., after several attempts were made to interview him, LVN 2 stated Resident A was alert, ambulatory and had behaviors that included hiding in other resident’s rooms, closets and bathrooms. LVN 2 stated Resident A walked constantly and at times would approach doors and push on them. LVN 2 stated when he came to work that night on 1/13/2021, he made his rounds and did a head count of the residents. LVN 2 stated at 12 a.m., on 1/14/2021, Resident A was in his room and at 1 a.m. the resident was seen in the hallway. LVN 2 stated Resident A was seen in his room at 2 a.m., on 1/14/2021. LVN 2 stated he took his break at approximately 2:30 a.m. to 3 a.m., and when his break was over he did his rounds and found Resident A was not in his room. LVN 2 stated he called his staff and they searched for Resident A inside and outside of the building and in the surrounding community, but they could not find Resident A. LVN 2 stated he called the police department and reported Resident A was missing from the facility. LVN 2 stated earlier that evening (1/14/2021) he saw another resident (Resident B) banging on the doors and throwing things, which was his normal behavior. LVN 2 stated he believed Resident B may have dislodged the door and the alarm possibly malfunctioned. LVN 2 stated the staff were responsible and assigned to monitor the hallways and doors but prior to Resident A eloping from the facility those assignments were not really enforced. During a review of the facility’s policy and procedure (P/P), dated in the year 2019 and titled, “Elopements and Wandering Residents,” the P/P indicated the facility ensures residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents. Alarms are not a replacement for necessary supervision. Adequate supervision will be provided to help prevent accidents or elopements. The facility failed to: 1. Ensure Resident A was adequately supervised on a locked unit, the locked unit was secured, alarms activated, and residents were closely supervised to prevent an elopement from occurring. 2. Follow their policy and procedure that stipulated, residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents. As a result, Resident A, who had a behavior of walking and pushing on doors was not being supervised, went missing from the locked unit of the facility on 1/14/2021 in the middle of the night, for over 20 hours. Resident A was found five miles away from the facility at the beach and brought back to the facility by police officers. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.