Every finding on record at Hunters Creek Nursing and Rehab Center

Based on interview, and record review, the facility failed to accurately obtain and document fluid intake for a resident on a fluid restriction for 1 of 2 residents reviewed for hydration status, out of a total sample of 11 residents, (#2).Findings: Review of the medical record revealed resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including type 2 diabetes, chronic obstructive pulmonary disease, chronic kidney disease, stage 4, and heart failure. Review of resident #2's medical record revealed a care plan for nutrition and hydration initiated on 7/23/22 and revised on 4/21/26. The care plan showed resident #2 was at risk for decreased nutritional status and dehydration related to diabetes, chronic kidney disease, edema, hyponatremia (low sodium) and hypoosmolality ( low levels of electrolytes and other fluids in the blood). The goals included remaining free from signs and symptoms of dehydration. The interventions indicated resident #2 was on a fluid restriction of 1900 milliliters (ml). Review of resident #2's physician orders revealed an order dated 4/28/26 for a fluid restriction of 1900 ml with a break down as follows: nursing - day shift 290 ml, evening shift 290 ml, night shift 120 ml; dietary - breakfast 720 ml, lunch 240 ml, and dinner 240 ml. The order instructed nurses to document ml provided by the nursing staff every shift. Review of the resident #2's Medication Administration Record (MAR) for April 2026 revealed the nurse documented n on 4/23, 4/25, 4/26 and yes on 4/27 (4 out of 6 entries during the day shift), instead of the measurement of ml of fluid. The MAR for May 2026 showed the nurse documented n on 5/13, 5/14, 5/18, and 5/19, (4 out of 21 entries during the day shift in May), instead of documenting the ml of fluid as ordered by the physician. On 5/21/26 at 3:30 PM, Licensed Practical Nurse (LPN) A stated resident #2 was on a fluid restriction due to low sodium. He indicated resident #2 could have 240 ml of fluids between the medication pass and water during his 8-hour shift. He explained he communicated with the Certified Nursing Assistant (CNA) to obtain and document the resident's fluid intake. When asked about the n documented in April and May, LPN A could not explain why he documented it. He stated n was not accurate. He then stated he did not communicate or coordinate with the CNAs regarding resident #2's fluid intake or restrictions. On 5/22/26 at 3:43 PM, during a telephone interview, the Captiva Unit Manager (UM) stated nurses were expected to document fluid intake accurately in the medical record. She indicated she did not know resident #2's MAR included n or yes instead of the actual ml measurements and acknowledged that documentation was inaccurate. She stated she was not sure how to verify the documentation as she was still learning her role as UM. On 5/22/26 at approximately 4:45 PM, while interviewing the Administrator, the Regional Clinical Services Director indicated they expected the medical records to be accurate. She reviewed resident #2's MAR for April and May and confirmed the documentation for fluid intake, including n and yes, was not accurate. Review of the facility's policy titled Intake and Output revised August 2023 revealed a purpose for, The nursing personnel per physician's order will keep an accurate record of a resident's fluid balance. The procedure for recording Intake included determining the quantity of liquid consumed and documenting the total intake at the end of each shift.

Based on observation, interview, and record review, the facility failed to ensure food products were stored correctly in the walk-in cooler, and failed to ensure the temperature of hot foods being held was taken before service in accordance with professional food service safety. Findings: 1. On 12/15/24 at 11:50 AM, during a tour of the walk-in refrigerator with [NAME] D, a small plastic bag holding approximately 12 turkey slices, dated 12/11 (five days ago) was noted. [NAME] D stated the facility policy was to discard perishable food items three days after they were opened, and she removed it to be discarded. Another plastic bag with approximately 20 slices of sliced ham, dated 12/10 (six days ago) was noted and [NAME] D stated it also should have been discarded after three days and she removed it. An opened and resealed plastic bag of shredded mozzarella cheese dated 12/08 (eight days ago) and an opened bag of goat cheese, resealed in a plastic bag was dated 11/21 (25 days ago) was noted and [NAME] D reiterated these also should have been discarded after three days and she threw the bags away. There were two loaves of Italian bread, resealed in a plastic bag, dated 12/06 (10 days ago) that was hard and stale to the touch and [NAME] D discarded it. [NAME] D explained she assisted the Certified Dietary Manager (CDM) with the management of the kitchen, so she was able to tour the kitchen while the CDM was not present. A few minutes later, both a previously opened plastic jar of mayonnaise and a plastic bottle of Italian salad dressing which was approximately 3/4 empty, had a sticker dated 11/19/24 which indicated the day they were received, but neither had a date to indicate when they had been opened. A tub of opened but undated sour cream was also found. [NAME] D discarded the sour cream and explained these items should have been dated when they were opened. Five packages of unopened (in original sealed plastic bag) turkey slices were noted in a box that had been received 11/26/24 (20 days ago). [NAME] D was not sure how long these could be kept before discarding and stated she would check with the CDM when he arrived. There was a previously opened 1/2 of an unsliced ham in a plastic bag dated 12/02 (13 days ago). [NAME] D confirmed this was outdated and she threw it away. A box contained three 10-pound tubes of raw ground beef were noted. The box had a sticker with a received date of 12/06/24 (nine days ago). [NAME] D confirmed there was not an expiration date and was unsure of how long this item could be kept before discarding. On 12/15/24 at 3:45 PM, the CDM stated the plastic bag holding the turkey slices, dated 12/11 should have been discarded after five days- today. He said the sliced ham, dated 12/10 should have been discarded yesterday. He stated the resealed bag of shredded mozzarella cheese, opened eight days ago, and the bag with the goat cheese opened 24 days ago, should not have been discarded as cheese could be kept longer than sliced meat. He acknowledged not being sure exactly how long it could be held but stated they could be kept awhile. The CDM stated he did not have access to the food labeling and storage policy at that time because an outside company provided their policies, but he could get it by tomorrow. The CDM stated the mayonnaise and Italian salad dressing needed to be discarded by their use by date but was not able to locate a use by date on the labels of these items in the refrigerator, nor the unopened ones in the dry storage area. The CDM could not show when these undated items were opened nor when they needed to be used or discarded. The CDM stated he was positive the sour cream should have a use by date on it but since it was already discarded, he did not have the container to find that date. He also confirmed the opened loaves of Italian bread from nine days ago should have previously been discarded. The CDM was unsure how long the five packages of unopened (but still sealed) turkey slices, could be kept, but would find out. He stated he was sure the unsliced ham should not have been discarded, but was not sure how long it could be kept and used. The CDM stated the box of raw ground beef had previously been frozen and was probably pulled from the freezer to defrost two days ago but had no label or documentation as to when that occurred. He stated he thought it could be kept in the refrigerator for about seven days after being frozen. The CDM stated they followed the standard policies of all food services operations, and he was aware staff was supposed to date items when they were opened. On 12/18/24 at 9:00 AM, the CDM stated he called his food distributor service to find out how long cheese could be kept after it was opened but had not received a return call. He said the only information he obtained at this point was a document he provided after a general computer search for the shelf life of shredded mozzarella cheese, and how long does crumbled goat cheese last? which is not considered a credible source for food service safety guidelines for vulnerable populations and public food service operations. The CDM stated moving forward the facility would get a policy for how long they were to keep cheese. 2. On 12/18/24 at 11:15 AM, a tray of individually portioned insulated bowls of chicken noodle soup was observed, on a shelf above the tray line. At 11:28 AM, after temperatures of all of the food items on the steamtable were taken by [NAME] D, the CDM acknowledged soups were usually portioned into individual bowls when food temperatures were taken, which usually started at 11:15 AM. The bowls of soup usually would be held in individual serving bowls, for approximately 25 minutes, until 11:40 AM, when tray line plating began. At 11:30 AM, the CDM asked [NAME] I to reheat the bowls of soup. At 11:38 AM, tray line started without the soup. At 11:43 AM, [NAME] I set the tray of reheated soup bowls back on the shelf above the tray line (without a heat source) and walked away. A Dietary Aide H, then took a bowl of the soup and placed it on a resident's lunch tray. By request of the surveyor [NAME] I took the temperature of the bowls of reheated soup, at 137 degrees Fahrenheit (F). [NAME] I stated she usually took the temperature of food after reheating it but didn't this time. She stated she was aware that reheated food needed to reach 165 degrees F before serving and removed the bowls of soup to again be reheated. [NAME] D then took a separate steam table pan of cream of chicken soup, which had also been sitting on the counter and not in a heated position on the steamtable, to be reheated. At 11:53 AM, the cream of chicken soup temperature was tested at 156 degrees F. [NAME] D then returned the cream of chicken soup to be reheated again. At 11:58 AM, the cream of chicken soup was found to be at 200 degrees and was carried down to the resident unit to be added to the appropriate resident trays which had already been delivered to the unit. On 12/18/24 at 3:30 PM, [NAME] I stated she had been trained by [NAME] D and the CDM at the facility. She stated the policy was to label and date foods after opening them and to use or discard all potentially hazardous foods which included cheese, after no more than 3 days. On 12/17/24 at 1:30 PM, the Regional Healthcare Manager provided the facility's food storage and labeling/dating policy. The facility's Food Storage and Labeling/Dating policy, dated 8/2023, described each food item package was to be labeled with the date of receipt, when it was opened, and when the item was stored after preparation. The policy indicated foods that have exceeded their expiration date should be discarded and to discard leftover prepared food items within 72 hours of their preparation. The policy included a government issued food storage principles and guidelines which indicated raw ground beef was to be used within one to two days of storage in the refrigerator, an unsliced, pre-cooked half of ham, was to be used or discarded within three to five days of opening, and vacuum-packed, sliced lunch meats were also to be used within three to five days from opening. It also indicated vacuum-packed, sliced and unopened deli meats should be used and discarded within two weeks of receipt and commercial mayonnaise should be used or discarded within two months of opening. The policy did not include any guidance for the storage life of cheese.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity for 4 of 15 dependent diners at the facility, out of a total sample of 32 residents, (#11 and #48). 1. Review of resident #11's medical record revealed she was readmitted to the facility on [DATE] with diagnoses including dementia, hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following a stroke affecting her right dominant side, dysphagia (difficulty swallowing), and aphasia (language disorder). Review of resident #11's Minimum Data Set quarterly assessment with Assessment Reference Date of 11/05/24 revealed a Brief Interview for Mental Status was not obtained because she was rarely or never understood. The assessment showed resident #11 was dependent on staff for eating and received a mechanically altered diet. On 12/17/24 at 12:18 PM, resident #11 was lying in bed with her lunch tray on her bedside table. Certified Nursing Assistant (CNA) E was assisting resident's #11 roommate and from across the room stated resident #11 was a feeder and she needed to help her with her lunch. On 12/17/24 at 3:59 PM, CNA E explained resident #11 was a feeder. She validated this was the term used for residents who needed assistance with their meals. CNA E stated she did not recall receiving training on assisting residents with their meals. On 12/18/24 at 9:21 AM, the Administrator stated residents who needed assistance with their meals were not supposed to be called feeders. She explained this was, a dignity issue. Review of the Clinical Competency Checklist for Nurses and CNAs signed by CNA E on 3/16/23 included privacy and dignity. Review of the facility's admission packet revealed a document titled Florida Nursing Home Residents' Rights and Responsibilities dated 12/29/22. The residents were informed the facility would treat them courteously, fairly and with the fullest measure of dignity. Review of the facility policy titled Resident Dignity & Personal Privacy dated 4/2024 revealed the purpose was to care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. The document read, Call individuals by their preferred name. If the roommate is in the room, speak in lowered tones, as appropriate, when discussing clinical or private issues with the resident. 50401 2. On 12/15/24 at 12:41 PM, CNA A was observed near a dining table with three seated residents. Referring to resident #48, CNA A told Registered Nurse (RN) C, the resident was a feeder. RN C replied, Oh, she's a feeder? then walked away with the meal tray and uncovered plate left in front of the resident. Seven minutes later, at 12:48 PM, RN C was observed as she fed resident #48 while standing over her. On 12/15/24 at 1:20 PM, review of the master roster of residents which was used by nursing staff during their shift, the term feeder was observed typed next to the names of several residents which indicated this terminology was commonly used at the facility. On 12/18/24 at 9:23 AM, the Administrator stated the facility policy and procedure for passing meal trays was to sit next to a resident and not stand over them while assisting with their meal. She added the nursing staff was not to set the meal tray next to resident or remove the lid until the nursing staff was ready to sit with and assist that resident.

Based on observation, interview, and record review, the facility failed to address a pharmacy recommendation for 1 of 5 residents reviewed for unnecessary medications, out of a total sample of 32 residents, (#75). Findings: Review of resident #75's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including Parkinson's Disease, congestive heart failure, type 2 diabetes, and abnormalities of gait and mobility. Review of resident #75's Minimum Data Set quarterly assessment with Assessment Reference Date of 11/05/24 revealed a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition. The assessment showed resident #75 received a scheduled pain medication regimen. He experienced pain occasionally and the intensity was rated 8 on a scale of 0 to 10. Review of the physician orders included an order for Lidocaine External Patch 4% dated 4/28/23. The Lidocaine Patch was to be applied to the right leg topically two times a day for pain. Review of resident #75's Medication Administration Record for December 2024 revealed the Lidocaine Patch was applied twice a day from 12/01/24 to 12/17/24. Review of a Consultation Report issued on 10/17/24 indicated resident #75 received a Lidocaine patch. The pharmacist recommendation read, Please ensure the following administration recommendations are followed: order should include instructions to remove after 12 hours, . , do not exceed 3 patches for up to 12 hours within a 24-hour period, document patch application and removal . The report was signed by the Director of Nursing (DON) on 10/23/24. On 12/18/24 at 12:17 PM, resident #75 stated he did not use the patch to his leg every day but when he did it stayed on and was not removed at night. On 12/18/24 at 12:27 PM, Licensed Practical Nurse (LPN) F stated she applied a Lidocaine patch every day to resident #75's right knee. She recalled a patch was usually on resident #75's knee when she applied a new one in the morning. She explained this was an over-the-counter medication and showed the box for this medication. Later at 12:53 PM, LPN F read the directions included in the Lidocaine patch box. She mentioned it read not to use more than one patch in a 12-hour period. She validated the patch stayed on resident #75 over 12 hours and had not been used as directed. On 12/18/24 at 1:19 PM, the Regional Nurse Consultant stated both the DON and Unit Manager were out that day and she could not answer why the pharmacy recommendation was not addressed. On 12/18/24 at 2:49 PM, during a telephone interview, the Consultant Pharmacist explained his responsibilities included to conduct a monthly medication regimen review. He stated he would review the previous month's recommendation the subsequent month to ensure completion. He indicated if the recommendation was not addressed, he reprinted the form and sent it to the DON. He shared using the Lidocaine patch for longer than recommended could lead to over-absorption. He concluded his expectation was the facility addressed the recommendations. Review of, Topical Lidocaine for Chronic Pain Treatment published by the National Library of Medicine on 9/29/21 included Practice Guidelines which were regularly published by manufacturers and researchers which included, Topical Lidocaine should be used as directed by health care professionals and according to directions of the manufacturer. (Retrieved from www.pmc.ncbi.nlm.nih.gov on 12/20/24). Review of the policy and procedures titled Medication Regimen Review (MRR) revised on 6/01/24 revealed the facility would encourage the physician/prescriber or other responsible parties receiving the MRR and the DON to act upon the recommendations contained in the MRR. The document read, For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected, .

Based on interview, and record review, the facility failed to ensure staff had the appropriate competencies and skills sets to carry out the functions of food and nutrition service to prevent potential food borne illness for 1 of 3 residents reviewed for food, of a total sample of 32 residents, (#1). Findings: On 12/16/24 at 11:47 AM, resident #1 stated she had diabetes and liked a snack before bed for good blood sugar control. She continued, she often requested a sandwich snack from the nursing staff but had frequently been told there wasn't a sandwich available so now she received an egg or tuna salad sandwich on her dinner tray each night. Resident #1 explained although she received the sandwich on her dinner tray she did not eat it right away but instead usually ate it anywhere from 10:30 PM to 12:30 AM. She added, often the only snacks available were graham crackers which didn't have the necessary protein content for good blood sugar control. She stated her dinner meal usually arrived before 6:00 PM and she tried to wait at least four hours before she ate her nighttime snack. On 12/17/24 at 12:05 PM, the Registered Dietitian (RD) stated the nursing staff had told her resident #1 liked a turkey sandwich for a nighttime snack and she received it when requested from nursing. She added, the Dietary staff kept bulk sandwiches in the nourishment room for residents to request from nursing and they usually left about five to ten sandwiches there per night. On 12/17/24 at 12:21 PM, the Certified Dietary Manager (CDM) provided the meal ticket for resident #1's dinner which included an egg or tuna salad sandwich on each dinner tray in addition to her dinner meal. The CDM stated they added the sandwich for the resident on her dinner tray because she requested it as her preference. He explained he had spoken with this resident frequently and told her she was not to keep the sandwich for the next day but instead should ask for a fresh sandwich. The CDM stated he thought that she requested to get one on her dinner tray because she didn't want to bother the nurses. He stated there was no record of when resident #1 started receiving these sandwiches on her dinner tray but recollected it had been longer than six months. He added that his night cook made sandwiches for all three nourishment rooms which were delivered as a bulk snack for any residents who requested them. The CDM stated if he knew a resident was keeping a sandwich from their dinner tray but not eating it until 10:30 PM, that it would be okay. He acknowledged another alternative would be to send sandwich later to the nourishment room with resident #1's name labeled on it if it was requested and ordered. On 12/17/24 at 1:00 PM, the RD acknowledged the resident's dinner meal ticket showed she received an egg or tuna salad sandwich with her dinner meal every evening to eat as an evening snack after 10:30 PM which had been occurring at least 6 months or longer. The RD responded it was not safe to keep the perishable sandwich in her room unrefrigerated for that amount of time. She said the facility could order a sandwich to be put in the nourishment room each evening with her name and room number on it so she could request it from nursing, which would be a safer alternative. On 12/17/24 at 3:00 PM, Certified Nursing Assistants (CNAs), J and K confirmed resident #1 got a sandwich at night on her dinner tray and ate it before going to bed. They stated she went to bed late, usually between 11 PM and 1 AM, but were not sure what the actual time was that she ate the sandwich as they were working with other residents. On 12/18/24 at 9:00 AM, the CDM stated moving forward the plan for resident #1's evening snack was to put her name on it in the nourishment room refrigerator and instruct the nurses this resident was to get this sandwich when she was ready to eat it for her evening snack. He added he should have asked the resident when she was going to eat the sandwich and going forward he would do this as know he realized that keeping a tuna or egg salad sandwich unrefrigerated for 3 hours was too long. On 12/18/24 at 9:23 AM, the facility's Administrator acknowledged it was the facility's responsibility to ensure residents received food in a manner that was safe for them regardless of any requests to receive a food item in a certain manner. She stated in addition to the dietary staff, the CNA's were also responsible to ensure food safety and to be aware of food left unrefrigerated at the resident's bedside.

Based on interview, and record review, the facility failed to provide appropriate care and services, consistent with professional standards of practice, to adequately evaluate skin integrity and promptly intervene to prevent the development and worsening of a pressure injury for 1 of 4 residents reviewed for pressure injuries, of a total sample of 9 residents, (#1). The facility's failure to identify early stages of skin breakdown, promptly initiate wound care and treatment, and develop nursing interventions to promote wound healing resulted in actual physical and psychosocial harm for resident #1. The resident's skin was intact on admission to the facility and within 12 days, she was diagnosed with a stage 4, full-thickness skin loss pressure injury. Two days later, resident #1 was transferred to the hospital for signs of a possible wound infection. She required a surgical wound debridement procedure and was discharged home from the hospital with a wound vacuum machine. Resident #1 became homebound, experienced a decline in her overall physical status due to decreased mobility, and suffered depression related to ongoing wound treatments and the inability to participate in her preferred social and religious pastimes. Findings: Review of the medical record revealed resident #1, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included gastrointestinal hemorrhage, posthemorrhagic anemia, and generalized muscle weakness. Resident #1 was transferred to the hospital on 7/11/24. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 6/27/24 indicated resident #1 was hospitalized for a gastrointestinal bleed and anemia. The document revealed she was alert, oriented, and followed instructions, and was at risk for pressure ulcers. The form showed on discharge from the hospital, resident #1 had no pressure injuries, other skin lesions, or wounds. Review of the facility's Admission data set dated [DATE] revealed the Admission Nurse noted resident #1's skin color was normal for her ethnic group, her skin temperature warm and dry, and her skin integrity was clear with no conditions present. The associated Admission Note dated 6/27/24 revealed the resident was alert and oriented and able to make her needs known. The note indicated a body assessment showed a small, white intact area on her sacrum and another white intact area on her left buttock. Review of a Post-Admission Skin Check dated 7/01/24 revealed the facility's Wound Nurse assessed resident #1 and noted. Skin Clear, no condition present. The document indicated the Wound Nurse utilized the Braden Scale, a tool used to predict the risk of developing pressure injuries, to evaluate resident #1 and obtained a score of 16 which indicated a mild risk for pressure ulcer development. A Weekly Skin Check dated 7/03/24 revealed resident #1 had a head-to-toe skin check which showed no skin impairments. Review of the Minimum Data Set (MDS) Admission assessment with assessment reference date of 7/04/24 revealed resident #1 had clear speech and no comprehension issues. Her Brief Interview for Mental Status score was 15/15 which indicated she was cognitively intact. The MDS assessment revealed resident #1 had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. Review of a Nursing Progress Note date 7/06/24 at 12:00 PM, revealed resident #1's assigned nurse, Licensed Practical Nurse (LPN) A, received a message from the resident's daughter via another nurse on the unit regarding a request to evaluate her mother's skin. LPN A noted resident #1 was in a therapy session at the time, and when she returned to the unit, she declined a skin evaluation and stated she preferred to wait until her daughter returned. The Progress Note indicated LPN A instructed the oncoming evening shift nurse to follow up. Review of the facility's Visitor Sign In-and-Out Log for 7/06/24 showed resident #1's daughter returned to the facility that afternoon and remained there from 3:30 PM to 7:15 PM. However, review of resident #1's medical record showed no evidence of follow up by nurses on 7/06/24 related to conducting a skin evaluation, notifying the physician, obtaining physician orders, or implementing appropriate preventative interventions. Review of a Change in Condition Evaluation note dated 7/07/24 at 2:43 PM, written by the Captiva/Key [NAME] Unit Manager (UM), revealed resident #1 had a new skin area on her sacrum that measured 7.5 centimeters (cm) x 4.0 cm x 2.5 cm. The document indicated the physician was notified of the wound and ordered a referral to the Wound Physician. Review of the Medication Review Report revealed a wound treatment order, dated 7/07/24, to clean resident #1's buttocks and wound area with normal saline solution, apply zinc oxide ointment, and cover with a dry gauze dressing every shift. Zinc oxide is a mineral ointment that is applied to the skin to treat minor skin irritations such as diaper rash, minor burns, or severely chapped skin (retrieved on 11/26/24 from https://www.drugs.com/mtm/zinc-oxide-topical.html). Review of a Skin Impairment Observation note dated 7/08/24 revealed the Wound Nurse evaluated resident #1 and identified a pressure ulcer on her sacrum that measured 8.5 cm x 3.5 cm x 2.5 cm and had a moderate amount of slightly bloody drainage. She noted normal surrounding tissue, no tunneling or undermining, and fully granulating, or healthy tissue. The document indicated the Wound Nurse changed the wound treatment. Review of resident #1's Medication Review Report revealed the new wound treatment order, dated 7/08/24, instructed nurses to cleanse the sacral wound with normal saline, apply calcium alginate, and cover it with a dry bordered gauze dressing once daily and as needed. Calcium alginate dressings are prescribed for wounds with moderate to heavy drainage such as pressure injuries and infected wounds (retrieved on 11/26/24 from www.woundsource.com/product-category/dressings/alginates#). Review of an Initial Wound Evaluation & Management Summary note dated 7/09/24 revealed the Wound Physician assessed resident #1 and determined she had a full thickness stage 4 pressure injury on her sacrum, of duration greater than three days. The wound measured 12 cm x 10 and the depth was not measurable due to presence of nonviable tissue and necrosis. The Wound Physician noted on one side of the wound, the tissue under the wound's edge was eroded to create a 3 cm pocket or area of undermining. The wound had a moderate amount of slightly bloody drainage. Sixty percent of the wound was comprised of thick adherent devitalized necrotic tissue and slough and the Wound Physician performed a surgical excisional debridement procedure. The document revealed the area surrounding the wound was a maroon/purple color, indicative of a deep tissue injury. The note read, The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 376 days. The National Pressure Injury Advisory Panel (NPIAP) defines a pressure injury or pressure ulcer as localized damage to the skin and underlying soft tissue usually over a bony prominence. The injury is caused by prolonged pressure and can present as either intact skin or an open ulcer, usually at the site of bony prominences such as heels, hips, sacrum, and coccyx or tailbone. According to NPIAP, a stage 3 pressure injury shows full-thickness skin loss with visible fat and/or granulation tissue. Slough and eschar (types of dead tissue) may be present but does not obscure the depth of tissue loss. A stage 4 pressure injury involves full-thickness loss of skin and tissue that leaves muscle or bone exposed. A deep tissue pressure injury (DTI) is a persistent non-blanchable deep red, maroon or purple discoloration or a blood-filled blister that is covered with intact or non-intact skin (retrieved on 11/26/24 from www.https://cdn.ymaws.com/npiap.com/resource/resmgr/NPIAP-Staging-Poster.pdf). Review of the medical record showed the Wound Physician revised resident #1's treatment order on 7/09/24 to cleanse her sacrum with normal saline, pat dry, and apply Calcium Alginate and Santyl, and cover with a gauze island border once daily and as needed. Santyl is a topical debriding agent that promotes wound healing by removing dead skin tissue (retrieved on 11/26/24 from www.drugs.com/mtm/santyl.html). Review of resident #1's medical record showed a care plan for risk for skin impairment was initiated on 6/27/24. The goal was to minimize the resident's risk for skin impairment. The only intervention instructed Certified Nursing Assistants (CNAs) to turn and reposition the resident with care rounds and as needed. The care plan focus was updated on 7/11/24 to show resident #1 had a stage 4 pressure injury to her sacrum, but there were no additional interventions developed. Review of a Progress Note dated 7/11/24 revealed resident #1 exhibited signs of a wound infection and the physician ordered her to be sent to the hospital Emergency Department (ED) for evaluation of her wound. Review of resident #1's hospital record revealed a General Surgery Consult Note dated 7/11/24 at 10:48 PM. The document indicated the resident was transferred to the hospital from a skilled nursing center via emergency medical services for evaluation of a sacral ulcer. On arrival at the hospital, her white blood cell count was elevated, indicative of an infective process, and she was started on three antibiotic medications. The surgeon's assessment of resident #1's wound showed it was a stage 4 pressure injury of 20 cm in diameter with purulent drainage, that goes to the bone. A Wound Consult Note dated 7/12/24 revealed a specialist physician assessed resident #1 and determined her sacral wound had exposed connective tissue, palpable bone in the center, and undermining. The note indicated the resident was scheduled for surgery the following day for operative debridement, with placement of a wound vacuum soon afterwards. An Infectious Disease Consult Note dated 7/13/24 revealed the physician revised resident #1's antibiotic regimen to treat the wound which he noted had necrotic skin, palpable bone, profuse drainage, and a foul odor. The hospital record revealed resident #1 was discharged home from the hospital on 7/19/24 with Home Health Care services for management of a 6-week course of intravenous antibiotics and a wound vacuum machine. On 11/12/24 at 9:34 AM, in a telephone interview, resident #1's daughter stated her mother was admitted to the facility at the end of June 2024 for short-term rehabilitation. She explained she expected her mother to obtain the benefits of physical and occupational therapy services while in the facility, and then return home. The resident's daughter stated prior to hospitalization for a bleeding ulcer, her mother was able to transfer herself from her bed to a wheelchair, use a walker, and complete self-care activities with minimal assistance. The resident's daughter stated her mother previously used an electric scooter and a wheelchair accessible van to attend church and participate in family activities. She explained she initially visited her mother in the facility early in the mornings to assist her to get out of bed, complete personal care, and get dressed so she was ready for the first therapy session. The daughter stated after a few days, facility staff instructed her to stop performing those tasks as therapists needed to incorporate them into her mother's therapy sessions. She explained she complied and started visiting later in the day when her mother was dressed, therefore she no longer saw her skin during care. Resident #1's daughter recalled on Saturday 7/06/24, she arrived in her mother's room and saw that she was not yet out of bed and ready for therapy. She offered to get her dressed and during care noted an open area on her mother's bottom. She stated the wound was approximately 3 to 4 centimeters long and had a small amount of drainage. The resident's daughter stated her mother's assigned nurse was not on the unit at that moment, but she informed the other nurse of the skin issue and also asked her to ensure the Wound Nurse was notified. She stated she never saw the wound again as it was always covered with a dressing, and when she asked, she was told the Wound Physician would continue seeing her mother weekly. Resident #1's daughter stated she was surprised when facility staff contacted her on 7/11/24 to inform her that her mother would be transferred to the hospital for evaluation of the wound. She recalled on arrival in the Emergency Department she was horrified when she saw her mother's wound as it was significantly larger and extended almost down to the bone. She said, I did not know it had worsened. I had no idea it had gotten so bad. The resident's daughter stated her mother was hospitalized for surgical debridement of the wound and had a vacuum machine placed to help with healing. She stated her mother was discharged home from the hospital and now required home health nursing services and physician home visits. On 11/12/24 at 2:40 PM, LPN B confirmed she completed a weekly head-to-toe skin check for resident #1 on 7/03/24. She recalled the daughter was present during the evaluation and the resident had no open areas or any other type of skin impairment on her body on that date. LPN B explained a few days later, the resident's daughter approached her and asked her to let the assigned nurse know that her mother had an open area on her bottom. LPN B stated when LPN A returned to the unit, she relayed the message and told LPN A to evaluate resident #1's skin issue. On 11/12/24 at 3:44 PM, in a telephone interview, LPN A recalled she completed resident #1's full body skin evaluation on admission. She verified the resident's skin was intact and she had no open areas on her buttocks or sacrum. LPN A explained that if the newly admitted resident had any skin breakdown, she would have discussed it with the attending physician when she called to review and verify her admission orders. She stated in addition to the initial skin evaluation, the facility had a Wound Nurse who conducted a thorough skin assessment soon after admission. On 11/13/24 at 9:50 AM, the Wound Nurse confirmed she completed resident #1's post-admission skin assessment on 7/01/24, four days after she was admitted to the facility. She validated the resident's skin was intact on that date. The Wound Nurse stated she re-evaluated resident #1 on 7/08/24, when the Captiva/Key [NAME] UM informed her there was a wound on the resident's bottom. She recalled resident #1 was alert, oriented, and cooperative during the procedure. The Wound Nurse explained she implemented a new treatment as the zinc oxide ointment was not appropriate for a wound of that depth. She stated the following day, the Wound Physician assessed the wound, diagnosed it as a stage 4 pressure ulcer, revised the treatment order, and made recommendations . On 11/13/24 at 10:19 AM, CNA C stated she usually rounded with the Wound Nurse to assist with turning and positioning residents during skin evaluations and wound care. She recalled she was with the Wound Nurse on 7/01/24 for resident #1's post-admission assessment and validated the resident's skin was intact. CNA C stated she accompanied the Wound Nurse about a week later and was shocked to see the wound that had developed. On 11/13/24 at 11:35 AM, CNA D stated she was sometimes assigned to care for resident #1. She recalled she once changed the resident's brief and noted redness but no open areas. CNA D stated she did not report the redness to a nurse, and a few days later she saw that the resident had a big wound. On 11/13/24 at 2:19 PM, the Director of Nursing (DON) acknowledged resident #1's hospital transfer form, facility admission skin evaluation, and the Wound Nurse's post-admission skin evaluation showed she had no open areas or pressure ulcers. The DON explained the wound developed, deteriorated quickly, and resident #1 was sent to the hospital for a possible wound infection. On 11/13/24 at 3:10 PM, in a telephone interview, CNA E stated she regularly cared for resident #1, often with assistance from her daughter(s). She explained the resident was incontinent of bowel but would immediately ask for help when she needed to be changed. CNA E stated even when the resident's family provided care, she observed her skin every shift. She stated to her knowledge, resident #1's skin was intact on admission, and she was not aware of any skin breakdown until informed by the resident's daughter. On 11/14/24 at 8:07 AM, in a telephone interview, resident #1's daughter stated staff never discussed any risk factors for pressure ulcers or interventions to prevent skin breakdown prior to the development of her mother's wound. The resident's daughter stated she believed staff did not observe her mother's skin thoroughly or often enough to identify the skin concern in its early stage as the facility was not aware of the open area until she brought it to the nurse's attention. She explained if she had been told how severe the wound was, she would have discussed interventions with her mother including returning to bed for intervals during the day. Resident #1's daughter confirmed her mother still suffered from the both the physical and psychosocial impacts of the wound she acquired in the facility over five months ago. The daughter stated her mother now needed a full body mechanical lift for transfers between her bed, wheelchair, and recliner as she was no longer able to stand. She explained her mother used to enjoy going in person to church three days weekly for social and service activities, and also enjoyed shopping outings with her daughters, but since her return home with the wound vacuum she has not been able to sit up for long enough to go anywhere. Resident #1's daughter explained the pressure wound significantly decreased her mother's quality of life and she was eventually prescribed antidepressant medication. Review of the facility's policy and procedure for Pressure Ulcer & Skin Care, revised August 2023, revealed a resident who was admitted to the facility without pressure injuries would not develop them, and a resident who developed pressure injuries would receive necessary care and services to promote wound healing. The procedures indicated licensed nurses were responsible for skin evaluations on admission and weekly thereafter. The interdisciplinary team would review resident assessment data to determine necessary care and collaborate with the physician to obtain and implement treatment orders that were appropriate for the resident and the type of wound. Review of the Center Facility Assessment, revised 10/18/24, revealed the facility was able to provide general care and services related to skin integrity, specifically pressure injury prevention and care.

Based on interview, and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected a skin condition related to an acquired pressure injury for 1 of 4 residents reviewed for pressure injuries, of a total sample of 9 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] for short-term rehabilitation. Her diagnoses included gastrointestinal hemorrhage, posthemorrhagic anemia, and generalized muscle weakness. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 6/27/24 indicated resident #1 was at risk for developing pressure injuries, and on discharge from the hospital, she had no pressure injuries, skin lesions, or wounds. Review of the Admission Data Set, dated 6/27/24, revealed resident #1's skin color was normal and her skin integrity was clear, with no conditions present. The linked Admission Note, dated 6/27/24, revealed a body assessment showed a small, white intact area on her sacrum and another white intact area on her left buttock. Review of a Post-Admission Skin Check dated 7/01/24 revealed the facility's Wound Nurse assessed resident #1 and she noted, Skin Clear, no condition present. A Weekly Skin Check dated 7/03/24 revealed resident #1 had a head-to-toe skin check which showed no skin impairments. Review of the MDS Admission assessment with assessment reference date of 7/04/24 revealed resident #1 was admitted to the facility from an acute care hospital on 6/27/24. Contrary to the hospital transfer form and the facility's admission assessment, Section M - Skin Conditions indicated the resident was admitted with two known pressure injuries that were unstageable due to the coverage of the wound bed by slough and/or eschar. The document revealed the pressure injuries were unhealed. The MDS assessment indicated that during the 7-day look back period, she received pressure injury care and had ointments applied to areas other than her feet. Section Z - Assessment Administration indicated Section M of the MDS assessment was completed by the Lead MDS Coordinator. The National Pressure Injury Advisory Panel (NPIAP) defines a pressure injury or pressure ulcer as localized damage to the skin and underlying soft tissue usually over a bony prominence. The injury is caused by prolonged pressure and can present as either intact skin or an open ulcer, usually at the site of bony prominences such as heels, hips, sacrum, and coccyx or tailbone. According to NPIAP, an unstageable pressure injury is defined as obscured full-thickness skin and tissue loss in which the extent of the tissue damage is not visible due to the presence of slough and/or eschar, types of dead tissue. Once the slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed (retrieved on 11/26/24 from www.https://cdn.ymaws.com/npiap.com/resource/resmgr/NPIAP-Staging-Poster.pdf). Review of resident #1's Medication Review Report revealed an admission order dated 6/27/24 for weekly skin checks every Wednesday during the day shift. The document showed no physician orders for ointments, wound care, or treatments during the look back period as noted in the MDS Admission assessment. On 11/12/24 at 1:46 PM, the Lead MDS Coordinator stated she obtained necessary information to complete MDS assessments from different sources including discussions in daily morning clinical meeting, review of the medical record, wound physician notes, documentation from the hospital, admission nurses' notes, and staff interviews. The Lead MDS Coordinator stated nursing staff informed her resident #1 had white areas on her bottom on admission, but her skin was intact as the areas were not open. The Lead MDS Coordinator was prompted to review resident #1's medical record and she validated the Post-Admission Skin Check done by the Wound Nurse on 7/01/24 and the Weekly Skin Check done on 7/03/24 indicated her skin was intact. She confirmed there was no nursing documentation of pressure injuries or other concerns, and no physician orders for wound care during the 7-day look back period. The Lead MDS Coordinator explained she possibly assumed that the white areas noted by the admission nurse were slough. On 11/13/24 at 9:50 AM, the Wound Nurse stated she evaluated resident #1's skin four days after admission and noted no skin concerns. She confirmed resident #1 acquired a stage 4 pressure injury in the facility. The Wound Nurse validated the MDS Admission assessment that showed the resident was admitted with two unstageable pressure injuries was inaccurate. On 11/13/24 at 2:19 PM, the Director of Nursing (DON) validated documentation in resident #1's medical record indicated on admission to the facility, she had two small white areas on her buttocks and sacrum, but no open areas. She acknowledged nursing staff, including the Wound Nurse, who evaluated the resident's skin after admission noted no skin impairments during the timeframe associated with the MDS Admission assessment. The DON explained all newly admitted residents' charts were reviewed by the interdisciplinary team, which included the Lead MDS Coordinator, and a pressure injury identified on admission would have been noted and discussed at that time. She stated during the State Survey Agency's current investigation, she discovered the Lead MDS Coordinator assumed resident #1 had pressure injuries based on documentation of small white areas on her skin. The DON stated the Lead MDS Coordinator should have reached out to her for clarification to ensure the MDS assessment was accurate. Review of the facility's policy and procedure for the Resident Assessment Instrument (RAI) Process, reviewed August 2023 revealed the RAI was used to provide staff with ongoing assessment information necessary for the development and modification of care plans that reflected appropriate, person-centered care and services for all residents. The policy indicated the MDS was the foundation of the comprehensive assessment and addressed essential screening, and clinical, and functional elements. The document revealed MDS assessment data would be obtained by observation of and communication with residents whenever possible and/or discussions with licensed and non-licensed staff, physicians, family member, and consultants. The procedure revealed each member of the interdisciplinary team would review the entire MDS assessment for accuracy before it was signed of as completed.

Based on interview, and record review, the facility failed to develop, implement, and update an appropriate baseline care plan to mitigate risk factors for skin impairment, and failed to incorporate person-centered interventions to promote healing for an acquired pressure injury for 1 of 4 residents reviewed for pressure injuries, of a total sample of 9 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] for short-term rehabilitation. Her diagnoses included gastrointestinal hemorrhage, posthemorrhagic anemia, and generalized muscle weakness. Resident #1 was transferred to the hospital for evaluation of a wound on 7/11/24. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 6/27/24 indicated resident #1 was hospitalized for a gastrointestinal bleed and anemia. The document revealed she was alert, oriented, and followed instructions, and was at risk for pressure ulcers. The form showed on discharge from the hospital, resident #1 had no pressure injuries, other skin lesions, or wounds. Review of the facility's Admission data set dated [DATE] revealed the Admission Nurse noted resident #1's skin integrity was clear with no conditions present. The linked Admission Note dated 6/27/24 revealed a full body assessment showed a small, white intact area on her sacrum and another white intact area on her left buttock. A Progress Note date 7/06/24 at 12:00 PM revealed resident #1's assigned nurse, Licensed Practical Nurse (LPN) A, received a message from the resident's daughter via another nurse on the unit regarding a request to evaluate her mother's skin. LPN A noted resident #1 was in a therapy session at the time, and when she returned to the unit, she declined a skin evaluation and stated she preferred to wait until her daughter returned. The progress note indicated LPN A instructed the oncoming evening shift nurse to follow up. Review of subsequent Progress Notes for 7/06/24 to 7/07/24 revealed no follow-up nursing notes to indicate either the evening or night shift nurses attempted to evaluate the resident's skin after her daughter returned to the facility. Review of a Change in Condition Evaluation note dated 7/07/24 at 2:43 PM, written by the Captiva/Key [NAME] Unit Manager, revealed resident #1 had a new skin area on her sacrum that measured 7.5 centimeters (cm) x 4.0 cm x 2.5 cm. The document indicated the physician was notified of the wound and ordered a referral to the Wound Physician. Review of an Initial Wound Evaluation & Management Summary note dated 7/09/24 revealed the Wound Physician assessed resident #1 and determined she had a full thickness stage 4 pressure injury on her sacrum that measured 12 cm x 10 cm with the depth not measurable due to the presence of nonviable tissue and necrosis. Review of resident #1's medical record showed a baseline care plan for risk for skin impairment was initiated on 6/27/24. The document indicated the resident was admitted with wounds to her left buttock and sacrum, which was inconsistent with the admission nursing skin evaluation. The care plan goal was to minimize complications related to skin impairment. An intervention dated 6/27/24 instructed Certified Nursing Assistants to turn and reposition the resident with care rounds and as needed. The care plan focus was not updated on 7/07/24 when the newly identified wound was assessed and reported to the physician. On 7/11/24, the day resident #1 was transferred to the hospital for evaluation of her wound, the document was updated to show she had a stage 4 pressure injury on her sacrum. However, the baseline care plan goal and interventions were not changed to reflect the necessary care and services to prevent worsening and promote healing of the pressure injury. The only active care plan approach remained to turn and reposition the resident with care rounds and as needed. On 11/14/24 at 10:48 AM, the Lead Minimum Data Set (MDS) Coordinator reviewed resident #1's baseline care plans and confirmed on admission, there was only one intervention developed related to the prevention of skin impairment, and that was to turn and reposition her during rounds and as needed. The Lead MDS Coordinator validated she updated the baseline care plan with five additional interventions on 7/12/24, the day after resident #1 was transferred to the hospital. She explained all members of the interdisciplinary team were responsible for updating care plans. She acknowledged the assigned nurses, the Unit Manager, and/or the Wound Nurse could have added appropriate interventions at any time. The Lead MDS Coordinator recalled someone told her resident #1 was noncompliant with approaches to promote skin integrity and she developed a care plan for behavior related to resisting care. She confirmed the resident's reported behaviors were not identified before the wound was discovered. The Lead MDS Coordinator verified it was essential for baseline care plans to be complete, accurate, and updated on an ongoing basis to properly meet residents' care needs. Review of the MDS Admission assessment with assessment reference date of 7/04/24 revealed resident #1 had clear speech and no comprehension issues. Her Brief Interview for Mental Status score was 15/15 which indicated she was cognitively intact. The MDS assessment revealed resident #1 had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. Review of resident #1's medical record showed no pattern of refusal of care in Progress Notes for June and July 2024. There was no documentation of attempts by nursing staff to educate resident #1 and/or her daughters regarding interventions to promote skin integrity such as the need to limit the time she spent seated on her scooter, prior to 7/09/24. Review of a Care Plan Meeting note dated 7/11/24 revealed resident #1's daughters attended via telephone. The note indicated the resident had a stage 4 pressure injury and she was at risk for wound deterioration due to noncompliance with repositioning, offloading of the wound, and skin assessments. The note read, .daughter acknowledges wound prior to admission.Daughter is aware of the risk of further deterioration [related to] resident's noncompliance. On 11/12/24 at 2:27 PM, and 11/14/24 at 8:07 AM, in telephone interviews, resident #1's daughter emphasized her mother had no wounds on her body prior to admission to the facility. When the Care Plan Meeting note was read to the daughter, she expressed shock, and stated she never had a conversation with the facility regarding her mother having wounds prior to admission. The daughter said, If the facility felt my mother came there with a wound, why weren't they treating it? She stated at no time was she informed of the severity of the wound or that her mother refused to comply with necessary interventions. She explained she visited her mother twice daily, and stated staff never mentioned any concerns related to adherence to the plan of care or development of appropriate approaches to promote wound healing. On 11/14/24 at 12:48 PM, the Director of Nursing (DON) was made aware of concerns related to the accuracy and appropriateness of resident #1's baseline care plans. After review of the behavior care plan and nursing progress notes, the DON acknowledged there was no documentation to support the alleged refusals of skin assessments, only that resident #1 asked for her daughter to be present on one occasion. When informed the resident's skin impairment care plan had only one intervention and was not updated after her pressure injury was discovered, the DON indicated the care plan in the medical record had several interventions related to promoting skin integrity and wound healing. She was informed those interventions were initiated on 7/12/24, the day after resident #1 was transferred to the hospital. She verified resident #1's baseline care plans did not reflect the facility's expected processes. Review of the facility's policy and procedure for Baseline Plan of Care, revised August 2023, revealed the facility would develop and implement a baseline care plan that included necessary instructions to provide effective, person-centered care. The document indicated the purpose of the baseline care plan was to promote communication between staff and prevent adverse events likely to occur soon after admission. The policy revealed any member of the interdisciplinary team could update the baseline care plan and nurses were expected to consider areas including functional status, health maintenance, and risk factors for pressure injuries.

Based on interview, and record review, the facility failed to protect the resident's right to be free from neglect by not ensuring staff implemented measures to mitigate the risk and prevent elopement for 1 of 3 residents reviewed for elopement, of a total sample of 13 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury, harm, and/or death. While resident #1 was out of the facility unsupervised, there was likelihood he could have died , been accosted by unknown persons, become lost, or hit by a vehicle. On [DATE], resident #1, a [AGE] year-old male was admitted to the facility from the hospital. While he was at the hospital, doctors determined he was at risk of harm and falls without 24-hour supervision and care and services to monitor him and implement measures to ensure freedom from harm and prevent known risks of endangerment. On [DATE] at 6:28 PM, the facility failed to provide appropriate care and services to prevent a physically and severely cognitively impaired resident, assessed to be an elopement risk, from exiting the facility unsupervised. The resident was allowed to exit the building unsupervised, and he walked approximately 0.2 miles across a high traffic 4-lane road with a curbed median into an apartment complex. The route along the way had wet, uneven terrain/pavement and curbs. The facility was unaware of the resident's elopement until a Certified Nursing Assistant (CNA) realized the resident was missing and determined a receptionist had unlocked the lobby door and allowed him to exit the building. Police found the resident in a nearby apartment complex parking lot with apparent minor injuries. The facility failed to implement preventive interventions per standards of care to mitigate the resident's risk of elopement. The facility's failure to identify the need for adequate supervision and ensure a secure environment placed all residents who wandered at risk. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was determined to be removed on [DATE] after verification of the immediate actions implemented by the facility. The facility corrected the noncompliance at F600 on [DATE]. The noncompliance at F600 was determined to be past noncompliance. Findings: Cross reference F689 Review of the medical record revealed resident #1, a [AGE] year old male was admitted to the facility from an acute care hospital on [DATE] with diagnoses of: encephalopathy (brain dysfunction), acute systolic congestive heart failure (inefficient blood pumping), pneumonia, acute respiratory failure with hypoxia (low blood oxygen), right bundle branch (heart vessel) block, type 2 diabetes mellitus, coronary artery (heart vessel) disease, dementia, abnormalities of gait (walking pattern) and mobility, lack of coordination, muscle weakness, cognitive communication deficit, and disorientation. The Admission Data Set form dated [DATE] documented resident #1 was alert and confused, had a language barrier (Spanish), and required a walker to walk safely. The form indicated the resident was at risk for elopement, and received high-risk antipsychotic (psychosis prevention), anticoagulant (blood thinner), diuretic (fluid removal), and antiplatelet (blood clot prevention) medications. The Care Needs section read, total care. The Minimum Data Set (MDS) 5-day Assessment with Assessment Reference Date [DATE] revealed during the look-back periods, resident #1 scored 5 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated he was severely cognitively impaired. The Mood assessment noted for ,d+[DATE] days, the resident had little interest or pleasure in doing things, felt down, depressed, or hopeless. Nearly every day, he had trouble sleeping and concentrating on things like reading or watching television. The Behavior Assessment noted the resident wandered for 1 to 3 days. Functional Abilities and Goals indicated the resident used a walker and needed help with functional cognition, eating, self-care, mobility, and to complete Activities of Daily Living (ADL). The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1 was alert and disoriented, but able to follow simple instructions. His decision-making capacity required a surrogate, he had risk alerts for falls, and his physical function for transferring and ambulation (walking) required an assistive device (walker) with 1 assistant. The hospital Speech-Language Pathology (SLP) report dated [DATE] indicated resident #1 required ,d+[DATE] supervision due to cognitive/memory deficits, the supervision required was described as, Direct 1:1 supervision. The hospital Occupational Therapy (OT) report dated [DATE] indicated resident #1 was oriented only to person, had decreased /impaired insight for safety judgement and decreased/impaired safety awareness. The hospital physician's History and Physical report dated [DATE] read, . he has declined cognitively, and it appears that his gross and fine motor skills are also impaired . The Order Summary dated [DATE] and Medication Administration Reports for [DATE] noted physician's orders that included an alerting bracelet to left ankle, check function and placement of alerting bracelet every night shift, psychiatric consultation, and Physical Therapy (PT)/OT/Speech Therapy (ST), evaluate and treat. Medication ordered on [DATE] included: Seroquel (antipsychotic) 25 Milligrams (MG) once daily and 50 MG at bedtime for psychosis, Lasix (diuretic) 40 MG once daily for congestive heart failure, Humalog (insulin) before meals and at bedtime as per sliding scale parameters, Glargine (insulin) 10 units at bedtime, Hydroxyzine HCI (antihistamine) 25 MG once daily for anxiety, Losartan Potassium 25 MG once daily for high blood pressure, Metformin (blood sugar lowering) 1000 MG once daily for diabetes mellitus, Terazosin HCI 2 MG at bedtime for high blood pressure, Apixaban (blood thinner) 5 MG twice daily for atrial fibrillation (heart arrhythmia) started [DATE], Glimepiride (blood sugar lowering) 2 MG every 12 hours for diabetes mellitus, and Midodrine HCI 10 MG three times daily for low blood pressure. The facility SLP Evaluation and Plan of Treatment notes dated [DATE] indicated the resident had, severe-profound cognitive-linguistic impairment characterized by deficits in orientation, memory, attention, naming, and problem solving . The facility PT Evaluation & Plan of Treatment Assessment Summary completed on [DATE] noted diagnoses of encephalopathy and lack of coordination, and showed the resident was referred for skilled PT following a recent hospitalization due to progressive weakness that led to non-ambulation. The assessment documented the resident had a fall risk and confusion with impulsivity, he required supervision/touching assistance for transfers and walking, the need for physical assistance to function safely in his home for transfers and ambulation, presented with impulsivity and poor to non-existent safety awareness resulting in increased risk for falling. The facility OT Evaluation & Plan of Treatment completed [DATE] revealed resident #1 was referred to OT due to issues with balance, a decrease in strength and falls/fall risk. The evaluation indicated his decision-making ability for routine activities was severely impaired . Another OT Treatment Encounter completed [DATE] revealed the resident was observed with behavioral impulses and difficulty with safety awareness. An Elopement Risk Screen and Care Plan dated [DATE], before the elopement, noted resident #1's risk score placed him as an elopement risk. The Care Plan's focus indicated the resident was at risk for elopement with a goal that read, Attempts to maintain safety will be provided through review date. The interventions included: alerting bracelet, check function every day and placement every shift, involve resident in appropriate activities, offer pleasant diversions; structured activities, food, television, books, offer reassurance and support as needed, and picture of resident kept in Elopement Binder(s). Other Care Plans included risk for falls, impaired cognitive function/impaired thought process, ADLs with staff assistance, and risk for impaired gas exchange/ineffective airway clearance. The Social Services Admission Evaluation dated [DATE] indicated the resident's cognitive patterns showed the resident had short-term and long-term memory recall problems, severely impaired abilities to make decisions regarding tasks of daily life, no acute changes in mental status from baseline. The evaluation showed the family expected the resident to remain in the facility as discharge to the community was not feasible. A Nursing Progress Admission Note dated [DATE] written by Licensed Practical Nurse (LPN) L read, Resident arrived on unit [DATE] at [4:45 PM] via stretcher accompanied by 2 transport personnel and numerous family members from [hospital name]. Resident is alert, confused most of the time No c/o [complaints of] pain or discomfort this shift. VSS [vital signs stable]. Resident is a fall risk but refused to use a walker or have staff assistance as he walked down the hall looking for an exit. [alerting bracelet] placed on left ankle. Bed in lowest position. In an interview on [DATE] at 1:03 PM, PT J recalled resident #1 received skilled therapy during his stay. PT J explained the resident needed supervision because he had confusion, and stated, we worked on gait training, balance, and lower extremity stabilization; balance and stabilization to prevent falls. On [DATE] at 3:15 PM, LPN L said when resident #1 was admitted to the facility on [DATE] during the 3:00 to 11:00 PM shift, he was on her assignment. The LPN recalled she completed the resident's elopement risk assessment within a few hours after he arrived, and found he was at risk. She explained, she notified the Captiva Unit Manager (UM) about the resident's behaviors and her concerns. She said an alerting bracelet was implemented before the end of her shift. LPN L said approximately 2 days later, during her 3:00 PM to 11:00 PM shift, she noticed the resident was wandering again. She stated, When the family left, he started trying to find a way out; he was determined he didn't want to stay here; he said he wanted to go out to the parking lot to go to his car; he was convinced his car was in the parking lot. In an interview on [DATE] at 2:54 PM, CNA B explained she knew resident #1 well and he was part of her assignment during her 3:00 PM to 11:00 PM shifts. She said CNAs used the information entered by the nurses in the Kardex to guide the care they provided to the residents. She said the resident spoke Spanish, was often focused on his family coming to visit, and he frequently asked for his wife. The CNA recalled on [DATE] during her shift, resident #1 walked around a lot, and she tried to redirect him. She stated, he was mentioning my wife is coming and he was coming out {of his room} again; he was wandering; he tried to go out to the back yard, and I stopped him. Review of resident #1's Visual Bedside Kardex for CNAs dated [DATE] listed under Safety interventions such as an alerting bracelet is placed, bed in lowest position, check alerting bracelet function every day, check alerting bracelet placement every shift, non-skid footwear, offer pleasant diversions, structured activities, food, television, and books. On [DATE] at 10:21 AM, in a telephone interview, LPN A explained she had resident #1 on her assignment for the first time during the 3:00 to 11:00 PM shift on [DATE], the day he exited the facility. She recalled, Registered Nurse (RN) G gave her report from the 7:00 AM to 3:00 PM outgoing shift and the RN told her resident #1 had dementia, was only alert to himself, and he wandered. She said the last time she saw resident #1 was around 6:00 PM the same day. On [DATE] at 10:45 AM, RN G explained she knew resident #1 well and took care of him during the 7:00 AM to 3:00 PM shifts his entire stay. She stated the resident spoke Spanish, and she was able to communicate with him well because she also spoke Spanish. The RN recalled the day following the resident's admission, she had been concerned about the resident's behavior and wandering. She said she told the Captiva UM the resident may need the secured unit or to be closer to the nurse's station however, the Captiva UM told her no beds were available there at that time. She explained, every day when she gave report to the 3:00 PM to 11:00 PM oncoming nurse, it was mentioned resident #1 was exit-seeking. The RN said during her shifts, she asked CNAs to keep closer checks on the resident but stated, no extra checks were officially put on him. On [DATE] at 3:27 PM, LPN O explained nurses and CNAs were expected to be aware of any residents who wandered, had increased anxiety, paced, or tried to find exits, especially if the behavior escalated. She said any concerns or changes were reported to the Unit Manager or Director of Nursing (DON). The LPN stated, We can put them on 1-to-1 observation, call the doctor, and they may consider them for the locked unit. It could be making more rounds on the patient to protect them. Logs are in the forms book. Review of the Psychotropic Medication Progress Note written by the Captiva UM dated [DATE] read, . Behaviors exhibited warranting the use of medications to include: Anxious, insomnia, not sleeping, pacing .Remove from situation/ensure resident safety. Interventions effective. On [DATE] at 10:40 AM, the Captiva UM explained CNAs and nurses were expected to recognize residents with increased agitation and wandering. She said CNAs notified nurses and nurses notified supervisors and the doctor. She stated some residents needed to go on the locked unit and if so, she brought the concern to the IDT to decide if that was needed. On [DATE] at 2:55 PM, in an interview with the Captiva UM and the Director of Clinical Services, the Captiva UM said she knew resident #1 well, had worked the day he was admitted and the days that followed. She recalled LPN L called her the night the resident was admitted and told her about his behaviors and elopement risk and the LPN told her, We've got an issue. The Unit Manager explained she told the LPN, We need to get this accomplished, and referred to implementing an alerting bracelet. She said nurses placed the bracelet on the resident that night. She recalled, resident #1 wandered in hallways, the living room, and the dining room and stated, We were concerned because of his dementia with the elopement evaluation; I had no bed on the locked unit; he was supposed to walk with a walker with therapy and therapy said without the walker he was unsafe, and he was to be with somebody to walk. She confirmed the resident was not placed on 1-to-1 supervision, She explained there was no documentation of additional supervision because the facility only utilized a handwritten log/form for 1-to-1 documentation, but not for other supervision types. She described other increased supervision interventions as, CNAs and nurses would be rounding more frequently; more frequently meant every ,d+[DATE] minutes. She said none of the nurses ever told her the resident had increased wandering or exit-seeking behaviors. In an interview on [DATE] at 10:50 AM, RN G, who spoke fluent Spanish recalled during the 7:00 AM to 3:00 PM shift on [DATE], the day the resident eloped, he was anxious, looking for his keys, and he told her he wanted to go home. She explained she was concerned about him wandering and he went to the locked unit door, so she asked CNAs to pay more attention to that. The RN stated, He was seeking the exits. On [DATE] at 12:40 PM, in a telephone interview, receptionist D said she had worked the 4:30 PM to 8:00 PM shift for approximately 5 months. She recalled on [DATE] at approximately 6:30 PM, resident #1 approached the locked lobby door. She said she thought the resident was a visitor and was going out to his car for a few minutes, so she didn't ask him to sign out or return a badge. She said the resident was wearing shorts and she remembered looking at the door camera but didn't recall seeing an alerting bracelet. She said the resident went through the parking lot and stood for a few minutes near the therapy exit doors at the side of the building. She recalled, after about 10 to 15 minutes, while she was busy on the phone and assisting others, she heard an overhead announcement that described the resident and his clothing. She said she checked the computer for resident #1's photo and realized it was the person she had recently let out of the building, so she called the nurse's station to let them know what had happened. She explained, she wasn't aware there was an elopement binder that contained the at-risk for elopement residents' information that was kept at the reception desk because no one had told her about it. She said she later reviewed the video footage that showed resident #1 was in the facility parking lot and near the side of the building for about 5 minutes before he walked towards the street. She said she should have asked the resident to sign out which may have stopped her from unlocking the door so quickly. Review of the weather history for the area on the afternoon/ evening of [DATE] revealed the presence of strong thunderstorms, and passing clouds with a high temperature of 79 degrees Fahrenheit, (retrieved from www.timeanddate.com on [DATE]). On [DATE] at 3:00 PM, the Captiva UM recalled she found the resident's alerting bracelet in the trash can in his room after he eloped. She explained the band looked like it had been cut off and staff found a butter knife on the floor near the dresser. The (Agency name) Calls For Service Summary report noted on [DATE] at 7:13 PM, revealed law enforcement was notified by facility staff that resident #1 was missing from the facility. At 7:18 PM, the agency changed the incident classification from Missing Person to Missing Endangered. At 7:39 PM, the report noted the resident was located by law enforcement and described resident #1 had tripped and fell and had blood on his face. The report indicated he was transported to a nearby hospital by emergency medical services personnel. The hospital emergency room physician's notes for [DATE] described resident #1's condition when he was found. The note detailed the resident had a laceration on his lip and an abrasion to his right knee. In an interview on [DATE] at 12:14 PM, the DON explained resident #1 was assessed to be an elopement risk the day he was admitted . She said behaviors were discussed every morning in clinical meetings and the Unit Managers were expected to implement any additional interventions when needed. She said the staff she interviewed after the incident told her resident #1 wandered. The DON stated, He looked for family that evening, he was looking for them. The night he got out they didn't come. On [DATE] at 1:46 PM, a telephone interview with Spanish translation was conducted with resident #1's wife. She said on [DATE], the day after the resident was admitted to the facility, the Captiva UM met with her and discussed use of the alerting bracelet as he was noted to be wandering and looking for their car. She said the family visited every day, and she wasn't aware he had become more anxious after that. She said had she known, the family would have visited more often to make him more comfortable. Resident #1's wife said her cell phone history showed on [DATE] at 7:54 PM, she received a call from the facility about the incident, and she immediately went to the hospital. She recalled, when she saw her husband, he was soiled, wet, disoriented, and anxious, with injuries to his face and knees. She said she knew he must have been very worried when he wasn't aware of what happened; and he was out there for so long. She said the resident told her some men brought him to that place and she stated, It gave me pity to see him in those conditions. She recalled she was very distressed and concerned to learn her husband had been missing, alone and unsupervised outside and stated, It was raining; he could have died ; he crossed the road. On [DATE] at 2:11 PM, in a telephone interview, the Medical Director recalled on [DATE] the facility notified him by telephone resident #1 had exited the facility unsupervised after the receptionist unlocked the front door. He conveyed, residents assessed to be at risk of elopement were at a higher risk of endangerment outside the facility while alone and unsupervised. In interviews on [DATE] at 1:00 PM, and on [DATE] at 12:13 PM, the Nursing Home Administrator, DON, Regional Clinical Director, Director of Clinical Services, and [NAME] President of Operations, the DON stated, We discuss behaviors every morning in clinical meetings and [the Captiva UM] will maybe bring attention that something else needs to be implemented. The Director of Clinical Services stated, The Receptionist didn't follow the policy to let the resident out. The [NAME] President of Operations explained the facility conducted an investigation after the incident and determined resident #1 would have been prevented from exiting if the receptionist hadn't unlocked the door for him. He acknowledged, He could have got further and been seriously hurt; the [alerting bracelet] doesn't supersede supervision. Review of the facility's standards and guidelines dated [DATE] titled Abuse & Neglect Prohibition SHCO20003.03 revealed neglect meant a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The document indicated facility supervisors would immediately correct and intervene in reported or identified situations involving neglect. Review of the facility's corrective actions were verified by the survey team and included the following: *On [DATE], the receptionist on duty was suspended. *On [DATE] an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held. *On [DATE], an audit was conducted to ensure all current residents were present, alerting bracelets and physician's orders were in place, and elopement risk evaluations were validated. *On [DATE], door system alarm checks for proper functioning were completed. *On [DATE], the Nursing Home Administrator educated the receptionist who was on duty [DATE]. *On [DATE], audits were conducted to ensure BIMS, evaluations, care plans, leave of absence and alerting bracelet orders were correct and present for all new admissions. *On [DATE], elopement book audits were conducted to ensure accuracy. *From [DATE] to [DATE], a total of nine staff assigned receptionist duties were re-educated by the Business Office Manager regarding the front door process and received competency checks. *From [DATE] to [DATE], a majority of staff were re-educated regarding Abuse, Neglect, and Exploitation that included at-risk resident elopement risk identification and implementation of preventive measures, protection of residents from harm, identification of resident neglect, signs and symptoms of elopement risk including wandering, and expectations for a missing alerting bracelet. *On [DATE], an Ad Hoc QAPI meeting was conducted to ensure all interventions were in place and root cause analysis was completed. *Ongoing audits were continued for new admissions to ensure accuracy of the BIMS, Leave of Absence, bracelets, alerting batch orders, and care plans. Review of the in-service attendance sheets noted staff participated in education on the topics listed above. From [DATE] to [DATE], interviews were conducted with 30 staff members who represented all shifts. The facility's staff included: 52 CNAs and 40 licensed nurses. Interviewed staff included: 10 CNAs, 4 LPNs, 4 RNs, 1 Housekeeper, 3 Receptionists, 1 Social Services Assistant, 1 Maintenance Assistant, 1 Business Office Manager, 1 Business Office Assistant, 1 Medical Records Coordinator, 1 Admissions Director, 1 Clinical Resource Coordinator, and 1 Physical Therapy Assistant. Eight of nine staff who were assigned receptionist duties were interviewed. All staff interviewed verbalized their understanding of the education provided. The resident sample was expanded to include 2 additional residents at risk for elopement/neglect. Observations, interviews, and record reviews revealed no concerns related to elopement for residents #3 and #4.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and a secure environment to prevent elopement for 1 of 3 residents reviewed for elopement, of a total sample of 13 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious life-threatening injury or even death. While resident #1 was out of the facility unsupervised, there was high likelihood he could have sustained serious life-threatening injuries, become lost, been accosted by a stranger, or hit by a motor vehicle and died . On [DATE] at 6:28 PM, resident #1 exited the facility's front entrance when the receptionist unlocked the door for him to leave the facility. He walked approximately 0.2 miles across a highly trafficked 4-lane road with a curbed median and into an apartment complex. The route along the way was noted to have wet, uneven terrain/pavement and curbs. The facility was unaware of the resident's elopement until a Certified Nursing Assistant (CNA) realized the resident was missing and it was determined the receptionist had unlocked the lobby door and allowed him to exit the building. Police later found the resident in a nearby apartment complex parking lot with apparent minor injuries. The resident's whereabouts were unknown to the facility until after law enforcement located him, more than an hour after he left. The facility's failure to identify and provide adequate supervision and ensure a secure environment contributed to resident #1's elopement and placed all residents who wandered at risk. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was determined to be removed on [DATE] after verification of the immediate actions implemented by the facility. The facility corrected the noncompliance at F600 on [DATE]. The noncompliance at F600 was determined to be past noncompliance. Findings: Cross reference F600 Review of the medical record revealed resident #1, a [AGE] year old male was admitted to the facility from an acute care hospital on [DATE] with diagnoses of: encephalopathy (brain dysfunction), acute systolic congestive heart failure (inefficient blood pumping), pneumonia, acute respiratory failure with hypoxia (low blood oxygen), right bundle branch (heart vessel) block, type 2 diabetes mellitus, coronary artery (heart vessel) disease, dementia, abnormalities of gait (walking pattern) and mobility, lack of coordination, muscle weakness, cognitive communication deficit, and disorientation. The Admission Data Set form dated [DATE] documented resident #1 was alert and confused, had a language barrier (Spanish), and required a walker to walk safely. The form indicated the resident was at risk for elopement, and received high-risk antipsychotic (psychosis prevention), anticoagulant (blood thinner), diuretic (fluid removal), and antiplatelet (blood clot prevention) medications. The Care Needs section read, total care. The Minimum Data Set (MDS) 5-day Assessment with Assessment Reference Date [DATE] revealed during the look-back periods, resident #1 scored 5 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated he was severely cognitively impaired. The Mood assessment noted for ,d+[DATE] days, the resident had little interest or pleasure in doing things, felt down, depressed, or hopeless. Nearly every day, he had trouble sleeping and concentrating on things like reading or watching television. The Behavior Assessment noted the resident wandered for 1 to 3 days. Functional Abilities and Goals indicated the resident used a walker and needed help with functional cognition, eating, self-care, mobility, and to complete Activities of Daily Living (ADL). The hospital Speech-Language Pathology (SLP) report dated [DATE] indicated resident #1 required ,d+[DATE] supervision due to cognitive/memory deficits, the supervision required was described as, Direct 1:1 supervision. The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1 was alert and disoriented, but able to follow simple instructions. His decision-making capacity required a surrogate, he had risk alerts for falls, and his physical function for transferring and ambulation (walking) required an assistive device (walker) with 1 assistant. A Nursing Progress Admission Note dated [DATE] written by Licensed Practical Nurse (LPN) L read, Resident arrived on unit [DATE] at [4:45 PM] via stretcher accompanied by 2 transport personnel and numerous family members from [hospital name]. Resident is alert, confused most of the time No c/o [complaints of] pain or discomfort this shift. VSS [vital signs stable]. Resident is a fall risk but refused to use a walker or have staff assistance as he walked down the hall looking for an exit. [alerting bracelet] placed on left ankle. Bed in lowest position. On [DATE] at 1:46 PM, a telephone interview with Spanish translation was conducted with resident #1's wife. The resident's wife said no one from the facility mentioned placing him on the locked unit before he had left the facility however, they told her after he eloped that he needed to be placed there if he came back from the hospital. She said the family visited every day, and she had not been aware he had become more anxious before he left. She said had she known of his behaviors, the family would have visited more often to make him more comfortable. She said her cell phone history showed on [DATE] at 7:54 PM, she received a call from the facility. She recalled someone informed her about the incident, and she immediately went to the hospital. She said she later viewed the video footage, and saw her husband tried to go out the locked front door, then the Receptionist unlocked it and let him out without checking him. She said she asked the facility why the Receptionist let him out so easily and they told her she no longer worked there. She recalled when she saw her husband at the hospital, he was soiled, wet, disoriented, and anxious with injuries to his face and knees. She said she knew he must have been very worried outside when he wasn't aware of what happened, and he was out there for so long. She stated, it gave me pity to see him in those conditions. She recalled she was very distressed and concerned to learn her husband had been missing, alone, and unsupervised outside and stated, it was raining; he could have died ; he crossed the road. Review of the weather history at the facility's zip code showed on [DATE] from 12:00 PM to 6:00 PM there were strong thunderstorms, and from 6:00 PM to 12:00 AM there were passing clouds with a high temperature of 79 degrees Fahrenheit, (retrieved from timeanddate.com on [DATE]). On [DATE] at 12:15 PM, the Nursing Home Administrator (NHA), Director of Nursing (DON), Regional Clinical Director, Director of Clinical Services, and [NAME] President of Operations acknowledged resident #1 eloped from the facility on [DATE] at 6:28 PM. The NHA stated the resident was last seen on the unit by nursing staff at 6:18 PM. The DON explained shortly after his admission, resident #1 was assessed by the admitting LPN to be a high elopement risk and an alerting bracelet was placed on his left ankle. She said the bracelet didn't alarm at the exit door when the resident left because he had removed it. The Regional Clinical Director said the receptionist didn't follow procedures and allowed the resident to exit the facility unsupervised. The NHA said the facility's investigation of the incident revealed the resident removed the alerting bracelet in his room with a butter knife which prevented the exit alarm from sounding, and the receptionist didn't verify who he was before she unlocked the door and allowed him to exit alone. In a joint review of the video footage captured on [DATE], from 2:00 PM to 6:30 PM, resident #1 was observed wandering the Captiva Unit hallways, common areas, dining room, the Captiva nurses station, employee hallway locked door, and his room. Twice, he was seen on the video as he attempted to open locked doors. The alerting bracelet was visible on the resident's left ankle until 6:16 PM, when the footage showed he walked out of his room, and down the hallway, attempted to open the locked secured unit door, went past the Captiva nurses station, and down the hallway to the front lobby reception area where he attempted to open the exit door at 6:28 PM. Within seconds, the receptionist unlocked the door, and the resident was seen walking out the door alone. The resident was viewed as he remained outside, wandered in the parking lot, stood near the building's therapy exit door, and wandered out of the parking lot towards the road at approximately 6:30 PM. The Social Services Admission Evaluation dated [DATE] indicated the resident's cognitive patterns showed the resident had short-term and long-term memory recall problems, severely impaired abilities to make decisions regarding tasks of daily life, no acute changes in mental status from baseline, the family expected the resident to remain in the facility as discharge to the community was not feasible, and the BIMS showed the resident scored 5 out of 15 that indicated he had severe cognitive impairment. In an interview on [DATE] at 1:03 PM, Physical Therapist (PT) J recalled resident #1 and explained the resident received skilled therapy during his stay and he needed supervision because he had confusion. The PT stated, we worked on gait training, balance, and lower extremity stabilization; balance and stabilization to prevent falls. In an interview on [DATE] at 3:15 PM, LPN L said when resident #1 was admitted to the facility on [DATE] during the 3:00 to 11:00 PM shift, he was included in her assignment. The LPN recalled she completed the resident's elopement risk assessment within a few hours after he arrived, and found he was at risk. She explained, she notified the Captiva Unit Manager about the resident's behavior and her concerns. She said an alerting bracelet was implemented before the end of her shift. She said during her 3:00 PM to 11:00 PM shift approximately 2 days later, she noticed the resident was wandering again. She stated, when the family left, he started trying to find a way out; he was determined he didn't want to stay here; he said he wanted to go out to the parking lot to go to his car; he was convinced his car was in the parking lot. The Order Summary dated [DATE] and Medication Administration Reports for [DATE] noted physician's orders that included an alerting bracelet to left ankle, check function and placement of alerting bracelet every night shift, psychiatric consultation, and PT/Occupational Therapy (OT)/Speech Therapy (ST), evaluate and treat. Medication ordered on [DATE] included: Seroquel (antipsychotic) 25 Milligrams (MG) once daily and 50 MG at bedtime for psychosis, Lasix (diuretic) 40 MG once daily for congestive heart failure, Humalog (insulin) before meals and at bedtime as per sliding scale parameters, Glargine (insulin) 10 units at bedtime, Hydroxyzine HCI (antihistamine) 25 MG once daily for anxiety, Losartan Potassium 25 MG once daily for high blood pressure, Metformin (blood sugar lowering) 1000 MG once daily for diabetes mellitus, Terazosin HCI 2 MG at bedtime for high blood pressure, Apixaban (blood thinner) 5 MG twice daily for atrial fibrillation (heart arrhythmia) started [DATE], Glimepiride (blood sugar lowering) 2 MG every 12 hours for diabetes mellitus, and Midodrine HCI 10 MG three times daily for low blood pressure. An Elopement Risk Screen and Care Plan dated [DATE], before the elopement, noted resident #1's Risk Score placed him as an elopement risk. The Care Plan's focus indicated the resident was at risk for elopement with a goal that read, Attempts to maintain safety will be provided through review date. The interventions included: alerting bracelet, check function every day and placement every shift, involve resident in appropriate activities, offer pleasant diversions; structured activities, food, television, books, offer reassurance and support as needed, and picture of resident kept in Elopement Binder(s). Other Care Plans included risk for falls, impaired cognitive function/impaired thought process, ADLs with staff assistance, and risk for impaired gas exchange/ineffective airway clearance. Review of resident #1's Visual Bedside Kardex for CNAs dated [DATE] listed under Safety interventions such as an alerting bracelet is placed, bed in lowest position, check alerting bracelet function every day, check alerting bracelet placement every shift, non-skid footwear, offer pleasant diversions, structured activities, food, television, and books. On [DATE] at 10:45 AM, Registered Nurse (RN) G, who spoke fluent Spanish recalled during the 7:00 AM to 3:00 PM shift on [DATE], the day the resident exited the facility, he was anxious and looking for his keys. She recalled he told her he wanted to go home. She explained she was concerned about him wandering and he went to the locked unit door, so she asked CNAs to pay more attention to that. The RN stated, he was seeking the exits. On [DATE] at 10:21 AM, in a telephone interview, LPN A explained she had resident #1 on her assignment for the first time during the 3:00 to 11:00 PM shift on [DATE], the day he exited the facility. She recalled, RN G gave her report from the 7:00 AM to 3:00 PM outgoing shift and the RN told her resident #1 had dementia, was only alert to himself, and he wandered. She said the last time she saw resident #1 was around 6:00 PM the same day. On [DATE] at 2:54 PM, CNA B explained she knew resident #1 well and he was part of her assignment during her 3:00 PM to 11:00 PM shifts. She said CNAs used the Kardex for information entered by the nurses for what care residents needed. She said the resident spoke Spanish, was often focused on his family coming to visit, and he frequently asked for his wife. The CNA recalled on [DATE] during her shift, resident #1 walked around a lot, and she tried to redirect him. She recalled on [DATE], close to 6:00 PM, she assisted the resident in his room with his supper tray and she left to assist other residents. She said she last saw the resident in his room when she passed by about ,d+[DATE] minutes later. She explained, during her shift he seemed anxious, and stated, he was mentioning my wife is coming, and he was coming out [of his room] again; he was wandering; he tried to go out to the back yard, and I stopped him. In an interview on [DATE] at 12:14 PM, the DON explained resident #1 was determined to be an elopement risk the day he was admitted . She said the staff she interviewed after the incident told her resident #1 wandered. The DON stated, he looked for family that evening, he was looking for them. The night he got out they didn't come. On [DATE] at 12:40 PM, in a telephone interview, receptionist D said she had worked the 4:30 PM to 8:00 PM shift for approximately 5 months. She recalled on [DATE] at approximately 6:30 PM, resident #1 approached the locked lobby door. She said she thought the resident was a visitor and was going out to his car for a few minutes, so she didn't ask him to sign out or return a badge. She said the resident was wearing shorts and she remembered looking at the door camera but didn't recall seeing an alerting bracelet. She said the resident went through the parking lot and stood for a few minutes near the therapy exit doors at the side of the building. She recalled, after about 10 to 15 minutes, while she was busy on the phone and assisting others, she heard an overhead announcement that described the resident and his clothing. She said she checked the computer for resident #1's photo and realized it was the person she had recently let out of the building, so she called the nurse's station to let them know what had happened. She explained, she wasn't aware there was an elopement binder that contained the at-risk for elopement residents' information that was kept at the reception desk because no one had told her about it. She said she later reviewed the video footage that showed resident #1 was in the facility parking lot and near the side of the building for about 5 minutes before he walked towards the street. She said she should have asked the resident to sign out which may have stopped her from unlocking the door so quickly. On [DATE] at 2:43 PM, receptionist N said she had trained receptionist D. She explained, the training included the sign in/out process, and they were expected to verify every person who exited the facility before the door was unlocked, even if there were people outside waiting to get in. She said the elopement book was used as a resource to identify current at-risk residents with a photo and their information. She said the book was updated every day with any new admissions and receptionists were supposed to check it at the beginning of their shift so they could look out for anyone who tried to exit unattended. She said after the incident, the facility implemented changes to the visitor badges, so they were brightly color coded to stand out more. Referring to the sign out process she stated, it's important because the patient can get hurt, lost, hit by a car, or end up in the hospital. On [DATE] at 10:42 AM, with the Business Office Manager, she said she was the supervisor for all receptionists, and she also provided their training. She explained, the elopement book included a photo and resident information, and all Receptionists were trained to use it, so they were more aware of who the at-risk residents were, and for quick access when there was an alert. She said off going and on coming receptionists reported to each other about daily updates. The Business Office Manager stated, what she didn't do is ask him to sign out; she thought he was a visitor, and he didn't have a bracelet to alert the door. On [DATE] at 3:00 PM, the Captiva Unit Manager recalled she found the resident's alerting bracelet in the trash can in his room after he eloped. She explained the band looked like it had been cut off and the ends of separation were jagged. She said staff found a butter knife on the floor near the dresser. The (Agency name) Calls For Service Summary report noted on [DATE] at 7:13 PM, revealed law enforcement was notified by facility staff that resident #1 was missing from the facility. At 7:18 PM, the agency changed the incident classification from Missing Person to Missing Endangered. At 7:39 PM, the report noted the resident was located by law enforcement and described resident #1 had tripped and fell and had blood on his face. The report indicated he was transported to a nearby hospital by emergency medical services personnel. The hospital emergency room physician's notes for [DATE] described resident #1's condition when he was found. The note detailed the resident had a laceration on his lip and an abrasion to his right knee. On [DATE] at 2:11 PM, in a telephone interview, the Medical Director recalled on [DATE] the facility notified him by telephone resident #1 had exited the facility unsupervised after the receptionist unlocked the front door. He conveyed, residents assessed to be at risk of elopement were at a higher risk of endangerment outside the facility while alone and unsupervised. On [DATE] at 12:13 PM, in an interview with the Nursing Home Administrator (NHA), DON, Regional Clinical Director, Director of Clinical Services, and [NAME] President of Operations, the DON stated, we discuss behaviors every morning in clinical meetings and [the Captiva UM] will maybe bring attention that something else needs to be implemented. The Director of Clinical Services explained receptionists were expected to review the elopement book at the top of their shift and stated, the receptionist didn't follow the policy to let the resident out. On [DATE] at 1:00 PM, the [NAME] President of Operations explained the facility's investigation found resident #1 would have been prevented from exiting the facility if the receptionist hadn't unlocked the door for him. He acknowledged, he could have got further and been seriously hurt; the wander guard doesn't supersede supervision. Review of the facility's standards and guidelines dated [DATE] and titled Resident Elopement SHCO20004.05 read, . The center strives to provide a safe environment and implements preventive measures to minimize elopement. A resident who leaves a safe area may have the potential to experience heat or cold exposure, dehydration and/or other medical complications or environmental hazards such as bodies of water or busy roadways. The guideline defined unsafe wandering as random or repetitive locomotion which may be goal-directed (e.g., the person appears to be searching for something or someone), non-goal-directed or aimless. The document described non-goal-directed wandering required a response from staff to address both safety issues and an evaluation to identify root causes as much as possible. The guideline gave examples if a resident moved about the center aimlessly it may indicate the resident was frustrated, anxious, bored, hungry, or depressed. The document explained an elopement occurred when a resident left the premises or a safe area without authorization and/or any necessary supervision. The guidance detailed when an employee observed an attempted exit by a resident, the staff should obtain assistance from other staff members in the immediate vicinity, if necessary; and instruct another staff member to inform the charge nurse or Director of Nursing services of the attempted exit. Review of the facility's undated standards and guidelines titled Receptionist Competency for Visitors and Vendors revealed visitors, vendors, and residents exiting the facility must return the badge and sign out with the time. The guideline directed that at no time shall a visitor or vendor be allowed to exit without turning in their badge and signing the time out. Review of the facility's corrective actions were verified by the survey team and included the following: *On [DATE], the receptionist on duty was suspended. *On [DATE] an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held. *On [DATE], an audit was conducted to ensure all current residents were present, alerting bracelets and physician's orders were in place, and elopement risk evaluations were validated. *From [DATE] to [DATE], majority of staff were re-educated regarding at-risk resident elopement risk identification and implementation of preventive measures, identification of exit-seeking residents and process to minimize risk, protection of residents from harm, signs and symptoms of elopement risk including wandering, expectations for a missing alerting bracelet, sign in/out process, and elopement books. *On [DATE], the NHA educated the Receptionist who was on duty [DATE]. *On [DATE], door system alarm checks for proper functioning were completed. *On [DATE], audits were conducted to ensure BIMS, evaluations, care plans, and Leave of Absence and alerting bracelet orders were correct and present for all new admissions. *On [DATE], elopement book audits were conducted to ensure accuracy. *From [DATE] to [DATE], a total of nine staff assigned receptionist duties were re-educated by the Business Office Manager regarding the front door process and received competency checks. *On [DATE], the front door process, Receptionist Competency for Visitors and Vendors was laminated and placed at the front reception desk. *On [DATE], an Ad Hoc meeting was conducted to ensure all interventions were in place and a root cause analysis was completed. *Ongoing audits were to be continued for new admissions to ensure accuracy of the BIMS, Leave of Absence, bracelets, alerting batch orders, and care plans. Review of the in-service attendance sheets noted staff participated in education on the topics listed above. From [DATE] to [DATE], interviews were conducted with 30 staff members who represented all shifts. The facility's staff included 52 CNAs and 40 licensed nurses. Interviewed staff included: 10 CNAs, 4 LPNs, 4 RNs, 1 Housekeeper, 3 Receptionists, 1 Social Services Assistant, 1 Maintenance Assistant, 1 Business Office Manager, 1 Business Office Assistant, 1 Medical Records Coordinator, 1 Admissions Director, 1 Clinical Resource Coordinator, and 1 Physical Therapy Assistant. Eight of nine staff who were assigned Receptionist duties were interviewed. All staff interviewed verbalized their understanding of the education provided. The resident sample was expanded to include 2 additional residents at risk for elopement. Observations, interviews, and record reviews revealed no concerns related to elopement for residents #3 and #4.

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for Dialysis received timely care and services to mitigate the risk for development of serious complications, from a total sample of 5 residents, (#3). Findings: Review of the medical record revealed resident #3, a [AGE] year old male was admitted to the facility from an acute care hospital on 12/04/23 with diagnoses that included end stage renal (kidney) disease, dependence on renal dialysis, myocardial infarction, congestive heart failure, severe cardiomyopathy, atrial fibrillation, chronic pulmonary edema, and type 2 diabetes mellitus. On 12/08/23, four days after admission, the resident required re-hospitalization , and was readmitted back to the facility on [DATE] with additional diagnoses that included metabolic encephalopathy (biochemical brain dysfunction), and hyperkalemia (high Potassium). The Minimum Data Set (MDS) 5-day/Discharge Return Not Anticipated Assessment with Assessment Reference Date (ARD) 12/08/23 noted the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated he was cognitively intact. The assessment showed there were no behavioral symptoms or rejections of evaluation or care. The assessment noted the resident required partial assistance from staff for mobility and to complete Activities of Daily Living (ADLs), was frequently incontinent of bladder and bowel functions, and he received hemodialysis during the look back period. The Care Plan showed there were Focus items for altered cardiovascular status, defibrillation/life vest, and ADL self-care performance. The plan of care did not include a focus item for Dialysis. The Order Summary Report showed physician's orders were entered on 12/04/23 for dialysis treatments with an 8:15 AM pick up time every Tuesday, Thursday, and Saturday, a specialized dialysis diet, fluid limits, and included the medications, Sevelamer HCI 3200 Milligrams (MG) with meals for hyperphosphatemia (electrolyte disorder), and Allopurinol 100 MG once daily for gout. On 12/05/23, the physician ordered STAT (immediate) laboratory tests of the resident's blood potassium level that read, high potassium level before dialysis. On 12/18/23 at 9:48 AM, resident #3 was observed lying awake and lying in bed. He recalled he experienced problems with getting dialysis approximately 2 weeks prior because his ride didn't show up and he had to go to the hospital. Review of a Nurses Progress Note completed by Licensed Practical Nurse (LPN) D on 12/05/23 at 3:30 PM read, Resident lab results reviewed Potassium 6.3 and BUN (blood, urea, nitrogen) 80. NP (Nurse Practitioner) (Advanced Practice Registered Nurse (APRN) I) notified and order to repeat labs when the resident return (returns) back from dialysis. Resident currently at dialysis. A Nurses Progress Note completed by the LPN on 12/07/23 at 5:39 PM read, Resident did not go to dialysis this morning because of transportation cancellation, dialysis center notified, NP (APRN I) notified and order to send patient to hospital for dialysis, resident and family member notified. In an interview on 12/18/23 at 12:50 PM, LPN D recalled resident #3 had unstable Potassium levels, and he had missed dialysis on 12/7/23. She explained there had been problems with the resident's transportation arrangements and he wasn't picked up. She said she reported the incident to APRN I who was concerned because the resident had a history of high potassium, and she told her she wanted the resident to go to the hospital to ensure he received treatment. The LPN said APRN I told her, This cannot wait until tomorrow. Review of the SNF (Skilled Nursing Facility) / NF (Nursing Facility) to Hospital Transfer Form noted on 12/07/23 at 2:00 PM, LPN D contacted the hospital emergency room to report resident #3's expected arrival. On 12/18/23 at 1:29 PM, the Assistant Director of Nursing (ADON) recalled she assisted nurses with resident #3's missed dialysis incident on 12/07/23. She said on 12/07/23, she arranged non-emergency transportation via telephone and email with the ambulance service. She explained when she left the same day at approximately 6:00 PM, she expected the resident would be picked up by 11:00 PM. Review of a Skilled Nursing Note completed by LPN C on 12/07/23 at 5:38 PM did not note the resident was awaiting transportation to the hospital for dialysis. On 12/18/23 at 3:15 PM, an unsuccessful attempt was made to interview LPN C by telephone. In a telephone interview on 12/18/23 at 1:50 PM, LPN F recalled she had resident #3 on her assignment during the 3:00 PM to 11:00 PM shift on 12/07/23. She explained by the end of her shift, the resident had not been picked up and she was concerned because the nurse from the previous shift reported the APRN expressed urgency and didn't want the resident to wait because he was high risk with unstable potassium. She said she reported to the oncoming 11:00 PM to 7:00 AM nurse, Registered Nurse (RN) G that she needed to call and check on the transportation status and notify the provider if the resident did not get transported to the hospital soon. On 12/18/23 at 2:00 PM, the ADON explained RN G was not available for an interview as she was out of the country and could not be reached. On 12/18/23 at 1:29 PM, the ADON explained when she returned to work on 12/08/23, the next morning she found that resident #3 had not been transported and was still at the facility. She stated she was concerned because she knew APRN I was concerned about the resident's unstable potassium level, and she didn't want him to wait that long. She explained nurses contacted APRN H and obtained orders to send the resident by emergency/911 to the hospital. On 12/18/23 at 4:15 PM, in a telephone interview with the non-emergency ambulance provider, the Supervisor checked their records for resident #3's service request on 12/07/23. The Supervisor explained the record showed there was a request made at 1:30 PM and the service was placed in a pending status that the facility was supposed to call with further information and at that time, a pickup time would have been provided. He said their records indicated they were not contacted by the facility again until 10:00 AM on 12/08/23. Review of a Nurses Progress Note completed by LPN C on 12/08/23 at 11:00 AM read, Resident transferred to (name) hospital for dialysis via 3 (county name) fire rescue/911. The hospital's (provider name) Kidney Specialists physician report dated 12/08/23 documented the resident missed dialysis while at the facility due to transportation issues with treatment plans for rehospitalization with diagnoses that included acute hyperkalemia with treatment plans that read, . arrange for hemodialysis to correct electrolyte abnormalities and to mobilize fluid. The Order Summary Report noted on 12/11/23, after the resident returned from the hospital, physicians ordered the additional medications, Metoprolol Succinate ER 25 Milligrams (MG) once daily for high blood pressure, and Apixaban 5 MG twice daily for clot prevention. On 12/18/23 at 1:29 PM, the ADON explained she expected nurses to contact the provider when there was a delay with physician's order implementation. She was informed that a review of resident #3's medical record had not revealed evidence that the 3:00 PM to 11:00 PM nor 11:00 PM to 7:00 AM nurses checked on the resident's transportation status or contacted the physician. She stated she did not know why nurses had not followed up, and said, they should have called. On 12/18/23 at 3:48 PM, the Director of Nursing (DON) explained she remembered on 12/07/23 at approximately 10:00 PM, she noticed resident #3's medical record showed he had not been transported to the hospital after his missed dialysis visit. She said she spoke to APRN H on the telephone, who told her the resident could wait until the following morning because dialysis wasn't done overnight in the emergency room . On 12/18/23 at 4:10 PM during a telephone interview, APRN H recalled the morning of 12/08/23, she received a telephone call from the DON who reported resident #3 had missed dialysis the prior day, was still at the facility, and they were still awaiting non-emergency transportation. She said she knew the resident's history and was concerned because dialysis had already been delayed by over 24 hours, and the emergency department process typically took several hours. She explained dialysis treatments were further delayed overnight which placed the resident at risk for serious complications. She said she was certain her conversation with the DON occurred the morning of 12/08/23. She stated she gave orders for the resident to be transported by 911 to ensure he arrived at the hospital timely. On 12/18/23 at 2:09 PM, during a joint telephone interview with APRN I and resident #3's Primary Care Physician (PCP), the APRN said she was familiar with resident #3. She recalled on 12/07/23 she was contacted by a nurse who informed her the resident had missed dialysis. She explained she told the nurse the resident could not wait until the next day because his Potassium level was elevated. She said she expected the resident would go to the hospital the same day, and she was not informed of the delay and need for 911 intervention. The PCP explained, nurses waited a few hours, the ambulance hadn't arrived, and the resident required emergency hospital services. He added, We can't make the nurses do what they are supposed to do. On 12/18/23 at 5:00 PM, the Regional Clinical Director said the facility did not have standards and guidelines related to provision of care and services to ensure dialysis treatments and/or transportation services were provided. Review of the facility's standards and guidelines titled Dialysis revised 6/23/15 read, PURPOSE To monitor and care for Hemodialysis Residents in the skilled nursing facility. The standards and guidelines titled Physician Orders revised 10/24/17 read, PURPOSE Physician orders are obtained to provide a clear direction in the care of the resident. The Facility Assessment Tool reviewed 10/17/23 read, . 3.7 Standards and Protocols The Management and staff familiarize and review what is expected from the medical practitioners and other healthcare professionals related to standards of care and competencies that are necessary to provide the level and types of support and care need for the resident population .

Based on interview and record review, the facility failed to implement physician's orders for laboratory testing for 1 of 5 residents reviewed for medication regimen review from a total sample of 38 residents, (#87). Findings: Review of the medical record revealed resident #87 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of thrombocytopenia (low platelets), anemia, major depressive disorder, anxiety, and insomnia. The Minimum Data Set modified admission assessment with Assessment Reference Date 6/01/2023 noted the resident was rarely or never understood, assessed as severely cognitively impaired, and had not had any rejections of evaluation or care. The assessment showed the resident received insulin injections for 6 days, opioid medication for 5 days, antianxiety medication for 6 days, and antidepressant, anticoagulant, and diuretic medication for 7 out of 7 days during the look back period. The Comprehensive Care Plan noted focus items for high-risk medications that directed nurses to monitor the resident for adverse effects and complete laboratory testing when required. The Psychiatry Evaluation Note for 6/01/2023 read, I ordered Depakote related labs that is CBC (Complete Blood Count), CMP (Complete Metabolic Panel), Depakote level in one week and repeat labs every three months. The Order Summary Report showed from 6/03/2023 to 6/14/2023 physicians orders included the anti seizure medication, Depakote 250 milligrams (MG) every 12 hours for mood disorder. The report did not include laboratory testing for a Depakote level. The Psychiatry Subsequent Note for 6/08/2023 read, Ordered Depakote related labs. No meds (medication) changed. The Consultant Report from the Pharmacy provider dated 6/05/2023 noted the resident, receives Depakote which may cause/worsen thrombocytopenia (low platelets). The most recent platelet count was low at 74 K/uL (thousand cells per microliter) on 5/29/2023. Recommendations: Please reevaluate and consider discontinuing Depakote. The Order Summary Report showed a physician's order on 6/16/2023 to double the Depakote dosage to 500 MG every 12 hours for mood disorder. The Lab Results Report dated 6/27/2023 showed resident #87's platelet count had worsened from 74 K/uL to a critical level of 35 K/uL. The nurses' Progress Notes on 6/27/2023 noted the physician was notified, ordered repeat tests for 6/28/2023, and directed that if the platelet levels dropped again to 30 K/uL or less, the resident required hospitalization for a platelet transfusion. On 6/29/2023 at 11:26 AM, the Unit Manager said the Psychiatric Advanced Practice Registered Nurse provided nurses with orders by progress notes, entering into the medical record software, or verbalized, and sometimes handwrote them. She said nurses transcribed any verbal or handwritten physician's orders into the medical record to implement. She reviewed resident #87's medical record and acknowledged there were orders to complete laboratory testing for Depakote levels on 6/01/2023 and 6/08/2023. She said the lab work was missed, and she could not explain why it had not been done. On 6/29/2023 at 11:39 AM, the Director of Nursing (DON) explained nurses transcribed physicians' orders and monitored residents for adverse effects of medications included in their plan of care. She reviewed resident #87's medical record and acknowledged there were labs ordered for Depakote levels included in the Psychiatry notes on 6/01/2023 and 6/08/2023. She stated the resident should have had lab tests done 3 weeks prior to monitor for toxicity. On 6/29/2023 at 4:21 PM, the DON explained nurses were expected to transcribe orders as part of their routine duties and responsibilities. She said nurses were provided education, training, and job expectations during new hire orientation, annually, and as needed. She said resident #87's medical record clearly showed the plan of care included interventions for lab orders that were not implemented and she concluded it happened due to, human error. The facility policy and procedures titled, Procedural Guidelines for Physician Orders SHCEDU0001.21 read, Authorized center staff should enter new Physician orders in the electronic ordering system as soon as they are received. The Facility Assessment Tool dated 10/31/2022 read, 3.4 . Registered Nurse/Licensed Practical Nurse On Hire and Annual . Transcribe Physician's Orders and administer medication according to facility policy and procedures.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices to prevent contamination during wound care for 1 of 3 residents observed for wound care out of a total sample of 38 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebrovascular disease, sepsis, urinary tract infection, bacterial disease, diabetes mellitus type 2, peripheral vascular disease, non-pressure wound left lower lateral back and pressure wounds sacrum and right lower lateral back. Review of resident #1's medical record revealed a care plan for actual skin breakdown revised on 6/19/23. The care plan indicated the resident had non pressure wound on left lateral lower back and pressure wounds right lower lateral back and sacrum. The care goal read, Resident will show signs of healing and remain free from complications .Wounds will be free from infection . Interventions included a wound care specialist for weekly wound evaluation/treatment. The physician's order for wound care dated 6/23/23 directed nurses to cleanse the lateral back wounds with normal saline, apply gauze wet with Dakins (bleach) solution and secure with gauze island border dressing daily. The wound treatment order dated 6/19/23 for the sacrum was to apply collagen powder and hydrogel with silver, secure with border with silver every day shift and as needed. On 6/28/23 at 2:25 PM, an observation was conducted of wound care for resident #1's right and left lower lateral back and sacral wounds. Licensed Practical Nurse (LPN) A assisted with positioning the resident and the Director of Nursing (DON) was present during care as well. The Wound Care Nurse performed hand hygiene, gathered wound care dressing supplies, and established a clean working area on the resident's overbed table. LPN A positioned the resident who was in bed onto her left side. The Wound Nurse removed the soiled dressing from the resident's right lower lateral back wound that had moderate amount of blood and yellowish drainage. The Wound Nurse, with the DON's prompting then washed her hands with soap and water, donned new gloves and applied new clean dressing per physician orders. LPN A then positioned the resident onto her right side and the Wound Nurse proceeded to remove the soiled dressing from the resident's left lower back wound. The dressing had moderate amount of bloody drainage. The Wound Nurse proceeded to clean the wound with normal saline and applied Dakins moist gauze and secured it with a border dressing. The Wound Nurse did not perform hand hygiene or change her gloves after she removed the soiled dressing and applied the clean dressing. Prior to doing wound care for the resident's sacral wound, the Wound Nurse removed her soiled gloves, washed her hands in the bathroom, donned new gloves and proceeded to remove the soiled dressing. The dressing had small amount of bloody drainage. The Wound Nurse proceeded to clean the sacral wound with normal saline, applied collagen powder and hydrogel with silver to wound bed using tongue blade and secured it with border dressing. The Wound Nurse did not perform hand hygiene or change gloves after removing the soiled dressing from the sacrum or application of new dressing. For 2 of 3 wounds the wound nurse did not perform hand hygiene and change gloves between dirty and clean procedures. On 6/28/23 at 2:55 PM, an interview was conducted with the Wound Nurse, DON, and Regional Nurse. The Regional Nurse assisted with the interview as the Wound Nurse's primary language was Spanish. They were informed the Wound Nurse did not perform hand hygiene or change gloves while observed doing resident #1's wound care of her sacral and left lower back wounds. The DON and Wound Nurse validated the findings. The DON acknowledged the Wound Nurse did the wound care to resident #1's right lower back wound correctly with her prompting but did not use appropriate technique for the sacral and left lower back wounds. The DON noted it was an infection control concern when a nurse did not remove soiled gloves and perform hand hygiene after removing soiled dressings. A facility policy and procedure for Dressings, Dry/Clean revised September 2013 read, The purpose of this procedure is to provide guidelines for application of dry, clean dressings .Steps in the Procedure .6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic biohazard bag. 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressings(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface .1. Using clean technique The facilities' policy for Hand Washing/Hygiene revised 6/5/19 read, The facility considers hand hygiene the primary means to prevent the spread of infections .Soap and water is required for hand hygiene when: a. Hands are visible soiled .c. After potential exposure to body fluid

Based on observation, interview, and record review, the facility failed to obtain a physician order for oxygen (O2) therapy and failed to ensure pulse oximetry was monitored per physician orders for 1 of 4 residents reviewed for oxygen therapy, (#4). Findings: Resident #4 was admitted to the facility on [DATE] with diagnoses that included heart failure and pneumonia. Review of the hospital transfer Agency for Health Care Administration Form 5000-3008 dated 12/28/22 noted resident #4's treatments included continuous oxygen at 2 LPM. The Minimum Data Set (MDS) assessment dated [DATE] revealed resident #4 had oxygen therapy as special treatment. Review of the resident's care plan initiated on 12/28/22 noted he was at risk for impaired gas exchange and ineffective airway clearance related to chronic respiratory failure. The care plan included interventions for medications and treatments as ordered. The plan of care did not include oxygen therapy. On 1/19/22 at 10:45 AM, resident #4 was observed in his room, asleep in bed with his eyes closed. He had oxygen via nasal cannula with concentrator set at 3 liters per minute, (LPM). On 1/19/22 at 11:10 AM, Registered Nurse (RN) A said she was assigned to resident #4's care on the day shift and acknowledged resident #4 received oxygen at 3 LPM. RN A checked the electronic medical record (EMR) and stated there was no physician orders for the resident to receive oxygen therapy. She stated she had not checked the medical record to ensure there were orders by the physician for oxygen therapy. RN A added there were current physician orders dated 12/28/22 to check the resident's oxygen saturation levels every shift (3 times per day) and notify the physician if less than 90%. She noted nurses had not entered the saturation levels and had only documented X as the order was not entered correctly into the Medication Adminstration Record (MAR) to ensure saturation levels were documented. On 1/19/23 at 12:45, the Director of Nursing (DON) said the unit manager should have included oxygen orders with his initial admission orders or the MDS nurse could have entered the oxygen orders. The DON acknowledged the nurses had only documented X in the MAR indicating they checked the O2 saturation levels instead of documenting the actual readings. On 1/19/23 at 1:05 PM, the Respiratory Therapy (RT) Manager reviewed the medical records and verified RT staff had documented the resident received oxygen at 3 LPM. The manager explained RT staff should have checked the physician orders to ensure the correct flow rate. On 1/19/22 at 5:15 PM, the 3 PM to 11 PM, Licensed Practical Nurse (LPN) C stated she was regularly assigned to resident #4 and added she was a new nurse and did not know how to enter orders for monitoring O2 saturation. The facility policy and procedure for Oxygen Administration revised 5/22/18 read, A resident will need oxygen therapy when hypoxemia [low oxygen in blood] occurs. Pulse oximetry monitoring, and clinical examinations determine the adequacy of oxygen therapy .Procedure: 1. Check physician's order .14.) Monitor the resident's response to oxygen therapy. Check pulse oximetry values during initial adjustments of oxygen flow. Once the residents is stabilized, check pulse oximetry as indicated by physician orders .

Based on interview, and record review, the facility failed to follow physician laboratory orders for 1 of 3 residents reviewed for changes in condition out of a total sample of 4 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure, pneumonia, chronic obstructive pulmonary disease, dependence on supplemental oxygen, sepsis, and bacteremia. Review of resident #1's medical record revealed a physician order to obtain labs 12/8/22 which included a CBC (complete blood count), BMP (basic metabolic panel), procalcitonin, and blood cultures times two. The facility nurse initialed the lab work was completed on 12/8/22 per the Medication Administration Record. Review of the paper and electronic medical records revealed no laboratory results. There was no documentation in the progress notes to indicate if specimen collection was or was not obtained by laboratory staff or if the resident refused lab work. A note by the Infectious Disease Advanced Practice Registered Nurse dated 12/13/22 noted no labs for review. On 1/19/23 at 4:15 PM, the Director of Nursing (DON) stated she could not locate any lab results and verified there was no documentation in the medical record of the resident's refusal. She explained the phlebotomist came to do labs when resident #1 was in therapy as evidenced by the lab sheet requisition form dated 12/9/22. She said the phlebotomist failed to report to the nurse that labs were not obtained. The DON acknowledged the physician was not notified. Review of the facility's policies and procedures for Diagnostics & Medications- Lab Results and Reporting implemented 5/23/17 read, Facility will obtain laboratory services to meet the needs of the residents. Laboratory services are provided when ordered by the physician or authorized practitioner in accordance with federal and state regulation .Notification of lab values will be documented in the resident's medical records .

Based on interview and record review, the facility failed to provide pharmaceutical services to ensure medications were administered according to physician orders for 1 of 6 sampled residents, of a total sample of 49 residents, (#70). Findings: Resident #70 was admitted to the facility on [DATE] with diagnoses including dementia, and depression. Review of the physician orders revealed an order dated 10/23/21 that read, Lorazepam tablet 0.5 mg [milligram], give one tablet by mouth every 4 hours as needed (PRN) for agitation related to anxiety for 14 days. Review of the Medication Administration Record (MAR) reflected the above order with a start date of 10/23/21 and a stop date of 11/03/21. The MAR had an X in all boxes for all dates after 11/03/21, to indicate that Lorazepam 0.5 mg should not be administered. Review of resident 70's Controlled Medication Utilization Record for Lorazepam 0.5 mg revealed nurses signed for removal of the medication on 5 occasions after the stop date of 11/03/21. Nurses documented removal of Lorazepam 0.5 mg one dose on 11/04/21, 3 doses on 11/15/21, and 1 dose on 11/16/21. There was no associated documentation on the MAR for administration of Lorazepam 0.5 mg. on these days. On 11/17/21 at 12:20 PM, Licensed Practical Nurse B acknowledged Lorazepam 0.5 mg was signed out on dates after the stop date of 11/03/21. She stated the medication should not have been given without obtaining a new order. On 11/17/21 at 12:35 PM, the Unit Manager explained the PRN or as needed Lorazepam order indicated the medication should have been administered for only 14 days and acknowledged the stop date of 11/3/21. She stated nurse leaders usually reviewed PRN orders for stop dates and could not explain why the medication was given after the stop date. The policy and procedure for Medication Pass Guidelines revised 4/25/17, read Medications are administered in accordance with written orders of the attending physician . Record the name, dose, route and time of the medication on the Medication Administration Record. Initial the record after the medication is administered to the resident.

Based on observation, interview and record review, the facility failed to post the nurse staffing hours daily and failed to maintain the daily nurse staffing hours form for a minimum of 18 months. Findings: On 5/05/21 at 10:00 AM, the Facility Staffing Form was posted at the receptionist's desk in the front lobby. The form was dated 5/03/21. The Director of Nursing (DON) confirmed the date on the form was not current. The DON stated the Scheduler was responsible for posting the required form every day. On 5/05/21 at 1:44 PM, the Scheduler explained that Human Resources & Payroll Coordinator (HRPC) was supposed to complete the form on that morning, 5/05/21. The Scheduler did not say who was supposed to complete the form on the previous day, 5/04/21, or why it was not completed. The Scheduler explained the form was posted by 8 AM every day. On 5/05/21 at 3:16 PM, the HRPC said she was not responsible for completing the Facility Staffing Form. She explained the nursing department should complete the form and post it in the reception area. The HRPC stated she did not have the forms for 5/04/21 or 5/05/21. The Scheduler was asked to provide nurse staffing postings for the previous 18 months. Review of the binders with retained Facility Staffing Forms revealed missing forms from the following dates: 10/17/20, 10/18/20, 10/23/20, 10/24/20, 10/25/20, 10/27/20, 10/30/20, 12/28/20, 12/29/20, 12/30/20, and 12/31/20. On 5/5/21 at 2:15 PM, the Scheduler said, I know nothing about the past forms. The facility's policy and procedure titled Nursing Scheduling/Staffing/Posting, revised on 7/26/16, included, The facility must post the nurses staffing data specified above on a daily basis at the beginning of each shift. This policy also noted, The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Based on record review and interview, the facility failed to provide adequate supervision and secure environment to prevent the elopement of 1 of 13 residents reviewed for elopement risk. (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was a high likelihood he could have fallen, become lost or been hit by a car. On 7/17/20 at approximately 5:00 PM, resident #1 exited the facility from a window in his room. He proceeded to walk across the facility's parking lot, across a grassy area to the parking lot of an adjacent Assisted Living Facility (ALF). At approximately 5:08 PM, the Administrator from the ALF informed the facility's Administrator that resident #1 was found in the parking lot of the ALF. The resident was returned to the facility unharmed at 5:18 PM. The facility's failure to provide adequate supervision and a secure environment resulted in Substandard Quality of Care. Past Non-Compliance at the Immediate Jeopardy level was identified as occurring from 7/17/2020 to 7/23/2020. Findings: Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #1's physician's orders [REDACTED]. The resident's medications included Eliquis 5 milligram (mg) a blood thinner, [MEDICATION NAME] 20 mg for depression, and [MEDICATION NAME] 2.5 mg for [MEDICAL CONDITION] depression. The resident's quarterly Minimum Data Set assessment with assessment reference date 5/23/20, revealed the resident's cognition was moderately impaired with a Brief Interview of Mental Status (BIMS) score of 10/15. The resident did not exhibit behaviors of wandering during the 7 day look back period. He required limited assistance with one-person physical assist for bed mobility, walk in room/corridor/on unit. He was assessed as being independent with transfers, required extensive assistance with dressing and personal hygiene, and supervision with eating, and toilet use. An Elopement Risk screen conducted on 2/26/20, and 6/04/20 revealed the resident was assessed as being an elopement risk. An Elopement Evaluation dated 5/21/20 revealed the resident was assessed as being at high risk for elopement. Documentation read, wanders aimlessly intervention included the continuation of an alerting bracelet. A nursing progress note dated 7/08/20 at 3:33 PM read, resident observed attempting to open window further than the 6 inches during window visit with family. Window closed; window secured. A progress note on 7/17/20 at 7:11 PM documented by Registered Nurse (RN) A read, The nurse was sitting at the desk and the resident was leaned on the counter looking at her without saying anything, then the nurse moved the computer to the medication cart to prepare medications and saw the administrator saying to the CNA's that there was a patient outside. We checked who it was and when we go to the room the window open, page code gray with the area and room number, we ran to look for him outside, and he was next to the building. We brought him back and we gave him water, the nurse checked his vital signs B/P 141/70, P 83, R-20, Temp 98.3. The nurse asked him if he was in pain and he denied pain, no distress observed, the nurse and aid did the skin check. A Focus Interdisciplinary Team (IDT) note dated 7/18/20 at 1:00 PM read, .On 7/17/20 resident was located outside facility when he exited his room through a window in which he manipulated approx. 10 minutes after nurse had observed him in no apparent distress or anxious state. Returned to facility without injury and at baseline .On 07/08/2020 resident attempted to open window during window visit in which he told staff he just wanted to kiss his wife. Window was secured by maintenance to avoid physical contact with visitors . The resident's care plan for Elopement Risk Focus created on 2/13/20 with revision on 9/02/20 noted, Remains at risk for elopement as evidenced by history of attempts to leave the facility unattended, impaired safety awareness. Another revision on 7/17/20 read, Resident was outside of building. Wanted to see wife to pay bills. On 11/30/20 at 10:48 AM, resident #1 stated he went out the window because he wanted to go home. The resident stated that there were too many people around and he was caught. Observation of the resident's window showed screws in the middle, and the sides, securing the window that prevented it from opening. On 11/30/20 at 12:05 PM, the Maintenance Director stated that sometime in July he was called back to the facility and was told that a resident got out through the window. He was directed by the Administrator to bolt the windows. He said the windows were bolted with sheet metal self-tapping 2 ½ inches screws that prevented the windows from sliding back and forth. The Maintenance Director stated he started bolting the windows first on the secure unit where resident #1 resided and completed the secure unit the same night. The windows were secured on the other two units the next day. On 11/30/20 at 3:17 PM, RN A stated that on 7/17/20 she was working a double shift on the secure unit. Resident #1 was included in her assignment for both shifts. RN A stated that the last time she saw resident #1 was between 4:45 PM-5 PM, when the dinner cart was brought to the unit. RN A stated she was sitting at the nurse's station, working on her computer. Resident #1 was leaned on the desk of the nurses' unit and quietly watched her. The RN stated she moved from the nurses' station to her medication cart to prepare medications for administration. She had not yet started the medication pass, when she saw the Administrator screaming, he's outside, he's outside. She indicated the Certified Nursing Assistants (CNAs) started to run, and she saw the resident #1's window was open approximately two feet. RN A said she did not see the resident and she called missing resident code. RN A stated she went through the service door hallway, through the employee parking lot, and resident #1 was standing with the Administrator and a CNA on the pavement opposite the fire exit door of the secure unit. Resident #1 was placed in a wheelchair and transported by the Administrator through the front doors of the facility. RN A stated the resident was asked why he exited the facility, and the resident told her he wanted to see his wife. The RN added that resident #1 was returned to his room, and offered food and water. She noted the resident behaved as if nothing had happened. She said he was placed on one to one supervision immediately after the incident. On 11/30/20 at 4:00 PM, CNA B stated that on 7/17/20 she was passing dinner trays at about 5 PM on the secure unit. Resident #1 came out of his room, and was standing by the meal cart, by the nurses' station. CNA B said she asked the resident if he wanted to eat in the dining room. He said no, he wanted to eat in his room. He then went back to his room. CNA B said that was the last time she saw the resident. CNA B noted that meal trays were passed in the dining room first, then to the rooms. She said resident #1 had not yet been served when the Administrator came and asked for the resident and she told him he was in his room. The Administrator said no someone said the resident was out of the building. CNA B stated that a code was called by RN A. CNA B said she and other CNAs searched room by room on the secure unit and the Administrator went outside. The Administrator found the resident and brought him back into the building. On the resident's return to the unit, CNA B noted that she and RN A completed a skin check on the resident and there were no injuries, or scratches. On 11/30/20 at 4:15 PM, the incident was reviewed with the Director of Nursing (DON). The DON stated, that on 7/17/20 at 5:08 PM, the previous Administrator received a phone call from the Administrator of the ALF. The ALF Administrator said, I have your resident over here. The DON said the resident took the window off the track, placed his walker through the window, and climbed out. He went behind a three feet hedge, placed his walker on the grass, and proceeded to the sidewalk, and went down a grade to a grassy area. She said the resident was returned to the unit at 5:18 PM. The resident was assessed, skin check completed, and there were no injuries. The resident was placed on one to one observation until the window was secured, then placed on every fifteen minutes checks. The DON stated that a screw had been previously placed on his window, where it could not slide open as he had previously tried to open it. After the incident on 7/17/20, the window was bolted. She stated that a re-enactment of the elopement was done by the Administrator on 7/18/20 at 5:43 PM. The DON noted the facility's investigation of the incident, identified the Root Cause of the elopement was due to Window visits. The probable elopement route resident #1 took was traced from his room window to the adjacent parking lot of the ALF. Resident #1 walked around a hedge, approximately three feet high in front of his window. He walked across the facility's parking lot, cut through an opening in the hedge to an inclination with a drainage grate then proceeded to the ALF parking lot which was approximately 101 steps from his window. The resident was 161 steps from the stop sign to a busy four lane heavily trafficked road. The resident could have sustained a fall with major injuries, could have been hit by a car in the parking lots of either facilities, or could have wandered on to the busy four lane street nearby. On 12/01/20 at 12:34 PM, the ALF Administrator stated that someone in her facility, either a visitor or a staff member said that there was a gentleman with a four-wheel walker in the parking lot. The ALF Administrator stated that her facility also had a resident who used a four-wheel walker, so she ran outside, and realized resident #1 was not an ALF resident. She recalled the resident was in the driveway of the ALF parking lot, at the round about in front of the facility, near the flagpole. The resident said he was looking for his wife and was going home. She noted the resident's name was on his walker and he was easily re-directed. The ALF Administrator said the Skilled Nursing Facility was the closest facility and she had the Administrator's phone number. She called the Administrator and told him that a resident was in the parking lot. She added that if he was not a resident of the facility her next call would be to the police. The ALF Administrator stated that she had the resident sit on the seat of his walker until the SNF Administrator and staff arrived. On 12/01/20 at 1:30 PM, the facility's Medical Director stated the facility called him on the day of the incident to discuss the elopement. He added that within a week they met again to discuss the incident and interventions implemented. The Medical Director said that all windows in the facility were bolted and all residents were reassessed for elopement risk. He noted that residents at high risk for elopement resided on the secure unit. The MD stated that resident #1's behaviors could have been be due to him missing his family. He said, the resident's family was doing window visits, and probably with his dementia, the resident thought if he lifted the window, he would see his family. On 12/01/20 at 4:18 PM, the Regional Nursing Consultant, (RNC) stated she had just left the faciity on [DATE] when she received a call from the Administrator. She said he told her he had a call from the ALF, that one of the residents was outside. She indicated the Administrator escorted resident #1 back to the facility. A full body assessment was completed, and the resident was placed on one to one supervision. She added that resident #1 remained on one to one supervision until all the windows were secured. He was then placed on every fifteen minutes checks until seen by psychiatry services to rule out emotional distress. The RNC stated the facility realized the resident disengaged a panel from the window which allowed him to exit through the window. She said all the windows were now bolted and could not be opened. She indicated all resident room windows on the secure unit were completed on the night of the incident. Review of the corrective measures implemented by the facility revealed the following: * Upon return to the facility on [DATE], resident #1 was immediately placed on one to one supervision. He was then placed on every 15 minute checks. * On 7/18/20 current residents at risk for elopement were supervised every 30 minutes until all the windows were secured. * On 7/17/20 the facility conducted elopement drills on all shifts, continued for 7 days until 7/23/20. Monthly elopement drills per shift were then resumed. * On 7/18/20 the nursing administration team conducted an elopement risk audit, which did not reveal any further residents at risk for elopement. * An Ad HOC QAPI (Quality Assurance Performance Improvement) was held regarding the resident's elopement, which included the facility's Medical Director on 7/17/2020 at 9:00 PM. * On 7/17/20 all room windows on the secured unit were securely bolted into place * In-service education regarding Elopement was initiated by the staff development coordinator on 7/17/20 for staff currently working, and at shift change on the 11 PM-7 AM, 7 AM-3 PM, and 3 PM-11 PM shifts prior to start of the employees shift. Staff were not allowed to work without receiving education. * On 7/18/20 room windows on the other two units were secured into place. * On 7/18/20 in- service regarding elopement sent to staff members via mass text messaging and automated calling service. On 7/22/20, 156/159 staff completed the education. Two staff were termed before returning, and one staff who was out for surgery was educated before returning to work. * 7/19/20 resident #1 was evaluated by the Psychiatric APRN (Advance Practice Registered Nurse), no new orders given. Based on conference with the IDT, and the Psychiatric APRN, resident # 1's room was changed to a window view to the courtyard instead of the parking area, to minimize any further attempts to leave the facility. Every 15 minutes checks discontinued. * 7/20/20 Education provided via certified mail to responsible parties for residents at risk for elopement regarding discontinuation of window visits. * 7/23/20 QAPI committee, reviewed and approved the QAPI plan, that included: the immediate changes, education, drills and audits. Determination made that the facility was in substantial compliance as of 7/23/20 at 1:30 PM. The facility's Assessment tool dated 1/21/20 and 10/15/20, last reviewed on 10/22/20 indicated that staff training/education and competencies provided on hire for RNs, LPNs, (Licensed Practical Nurse) and CNAs included: Preventing and Responding to Elopement. Staff interviews conducted with 17 staff (6 RNs, 5 LPNs, and 6 CNAs) from 11/30/20 at 10:55 AM to 12/2/20 at 4:00 PM revealed the facility had provided education on elopement, and that elopement drills were being conducted. Clinical record reviews were conducted for thirteen (13) current residents. The residents' elopement risk assessments were current, physician's orders [REDACTED].

Based on interview and record review, the facility failed to provide incontinence care in a timely manner for 1 of 3 residents reviewed for activities of daily living, (ADL) of a total sample of 50 residents, (#33). Findings: Resident #33 was admitted to the facility on [DATE] with her most recent readmission on 12/09/19. Her [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment with assessment reference date 12/14/19 revealed the resident's cognition was moderately impaired with a brief interview of mental status (BI[CONDITION]) score of 10/15. The resident required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, and was always incontinent of bladder and bowel. On 02/25/20 at 9:00 AM and at 4:11 PM, resident #33 stated that last night, 2/24/20 she was wet and had a bowel movement, and used the call light to call for assistance. She said she put her call light on, waited for half an hour, with no response. She said she then started calling out, hello, hello. After 10 minutes of calling out, someone came into her room. The resident stated she told staff that she was covered in urine and needed to be changed. She said the staff member told her to wait a minute as she would get someone to assist. The resident stated that she was not changed until this morning on 2/25/2020 at about 9:30 AM. 02/25/20 at 5:12 PM, the Captiva Unit Manager, (UM) stated that a grievance was placed by the resident this morning regarding the incident. The UM stated that the facility had cameras that monitored the hallways. She further stated that video footage could be reviewed to see if call lights were on, and when staff responded to the call lights. On 02/26/20 at 10:22 AM, the Administrator and Director of Nursing (DON) stated that a grievance was started on 2/26/20 regarding resident #33's concern of not being changed in a timely manner. The Administrator said the resident told the Social Services Director (SSD) that the incident happened sometime after 3 AM on 2/25/20. Camera footage for 2/25/20 from 3 AM-6:30 AM was viewed with the Administrator and the DON. Footage showed licensed practical nurse (LPN) D entered resident #33's room at 3:17 AM and came out of the room at 3:18 AM. At 4:15 AM, certified nursing assistant (CNA) E went into resident's room. As per the DON, CNA E stated she asked the resident if she wanted to be changed, and the resident stated she was fine. At 4:46 AM, LPN D went into the resident's room. The DON stated, that LPN D told her the resident's call light was on, and the resident asked to be changed. Both the Administrator verified that there was a period of an hour between the time when LPN D responded to the resident's call light, and when the CNA went into the resident's room. The DON said LPN D reported that she turned the resident's call light off, came out of the room, but forgot to tell the CNA. LPN D did not provide incontinence care to the resident. The DON stated that the 7AM- 3 PM CNA F said the resident was wet when she changed her at approximately 8 AM. On 02/26/20 at 11:18 AM, registered nurse (RN) G stated that resident #33 was able to make her needs known, and if the resident told him she was wet, he would expect the resident to be changed within 10-15 minutes. On 02/26/20 at 5:00 PM the DON stated, that when a resident said they were soiled, someone needed to go in and get care done as soon as possible. On 02/26/20 at 5:53 PM, LPN D stated that she worked with resident #33 on [DATE] on the 11PM-7AM shift. LPN D stated she answered the resident's call light, and the resident told her that she was wet. LPN D said she told the resident she would let the CNA know. LPN D stated resident#33 was very alert and used the call light when she needed something. LPN D stated she saw CNA E go into the resident's room, but she did not see if the CNA changed the resident. LPN D sated, that her expectation was that the resident should be changed immediately. LPN D said she did not change the resident. She reported that the CNA did not inform her that when she approached the resident, the resident stated that she was fine. On 02/27/20 at 9:10 AM, the Social Services Director (SSD) stated that a grievance was started on resident #33 on 2/25/20. She said resident #33 stated she was soaking wet and had put her call light on around 3 AM on 2/25/20. She added that a staff came in, said she would be right back, turned off the call light, but did not come back. The resident reported she got changed by another CNA at 9AM. The SSD stated resident #33 was alert, oriented x 2 and able to make her needs known. On 02/27/20 at 10:54 AM, the DON and Administrator stated that incontinence care was not provided to resident #33 in a timely manner. A review of the resident's care plan for Continence Focus revised on [DATE] included interventions to monitor for episodes of incontinence and provide incontinent care after episode of incontinence; maintain privacy and dignity during care. The facility's policy and procedure Personal Care Needs Policy with revision date 4/10/2019 read, A patient who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene.

Based on interview and record review, the facility failed to implement interventions to promote healing of a stage III pressure ulcer for 1 of 1 resident reviewed for pressure ulcers, of a total sample of 50 residents, (#7). Finding Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The resident's current physician orders [REDACTED]. [MED] is a product used to help the healing [MEDICAL CONDITION] skin ulcers .It works by helping to break up and remove dead skin and tissue. (WebMD) The quarterly minimum data set (MDS) assessment with assessment reference date 11/14/19, revealed that the resident was rarely/never understood, and had total dependence on staff for all activities of daily living. The resident was assessed as being frequently incontinent of bladder and bowel. The Wound Rounds note dated [DATE] read, Resident was seen by wound care MD (medical doctor) for unstageable wound of the right medial sacrum 3.4 x 2.5 (centimeters).recommend Foley (indwelling urinary catheter) due to resident constant moisture to promote wound healing. On 2/11/20 Wound Rounds documentation read, Resident was seen by wound care MD for unstageable wound of the right medial sacrum 2.5 x 4.7 x 0.8 .Debridement was performed without any complications .recommend Foley due to resident constant moisture to promote wound healing ., notified MD orders was given [MEDICATION NAME] for dribbles. A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. (eMedicineHealth) On 2/18/20 the Wound Rounds note read, Resident was seen by wound care MD for Stage 3 wound of the right medial sacrum 4 x 3.8 x1 . Debridement was performed.skin irritation superficial breakdown due to heavy wetting. The resident's Wound Evaluation & Management Summary dated [DATE]20 read, She has an unstageable (due to necrosis) of the right medial sacrum for at least 2 days duration. Measurements were, 3.4 cm (centimeter) x 2.5 x not measurable, and the wound had 25% slough. Debridement was performed to remove necrotic tissue and establish margins of viable tissue . recommend Foley for wound healing. Documentation indicated, that The clinical documentation for this consultation was made available to the referring physician .also made available to the skilled nursing facility at any time for placement in the skilled nursing facility record. A handwritten note documented on the Wound Evaluation & Management Summary for [DATE]20 read, Recommendation noted for placement of Foley-will reassess wound on next visit. D/W (discuss with) ID (infectious disease) but due to recent antibiotic we will wait on Foley. On 2/11/2020 the wound measurements were 2.5 x 4.7 x 0.8 cm. The wound care physician's documentation read, Stage 3 pressure wound of the right, medial sacrum-improved evidenced by decreased necrotic tissue. Recommendations included Foley for wound healing. On 2/18/2020 the wound measurements were 4 x 3.8 x1 cm, and documentation read, This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of a biofilm. Wound progress: Deteriorated . Stage 3 pressure wound of the right, medial sacrum-deteriorated due to urine contamination. Recommendations included: 2.4.20 recommend Foley for wound healing; 2.18.20 recommend Foley for wound healing. On 2/25/2020 wound measurements were 4.5 x 3.5 x 2 cm. Documentation read, Stage 3 pressure wound of the right, medial sacrum-deteriorated due to patient non-compliance with wound care, incontinence. Recommendations remained the same as the previous visit. The Advance registered nurse practitioner (ARNP) notes for resident #7 dated 2/11/20, read, Noted wound improvement without Foley .will f/u (follow up) with wound MD. No other documentation could be identified from the ARNP, to indicate follow up with the wound care MD was done, or that the repeated recommendation for a Foley urinary catheter for wound healing was addressed. On 02/27/20 at 8:59 AM and at 9:22 AM, the wound care nurse stated that the resident's wound to her sacrum was a facility acquired ulcer and was unstageable. She stated that the resident was being followed by the wound care physician weekly, and daily dressings were done by the wound care nurse. The wound care nurse stated that resident #7 was a frequent wetter and was seen by the wound care physician on Tuesday 2/25/20 and he recommended a Foley. The wound care nurse said she must get approval from the resident's primary care physician (PCP) for the insertion of the Foley, and the PCP was made aware of the recommendation on 2/26/20. Review of the wound evaluation & management summary revealed that the wound care physician made the recommendation for a Foley for wound healing on [DATE], 2/11/20, 2/18/20 and 2/25/20. On 02/27/20 at 2:25 PM the Director of Nursing (DON) stated the insertion of a Foley was discussed with the PCP. She said the PCP did not want to go the route of a Foley, due to the resident's history of frequent urinary tract infections. The DON stated, that the PCP said resident #7 had urogenic bladder, and overflow of urine, and started the resident on [MEDICATION NAME]. The PCP had now decided to go with the Foley, and orders for the Foley were placed today 2/27/2020. The resident's current physician orders [REDACTED]. an order for [REDACTED]. The DON stated that the wound care nurse failed to initiate the physician's orders [REDACTED]. On 02/27/20 at 3:14 PM the ARNP stated that she was aware of the wound care physician's recommendation for a Foley for resident #7. The ARNP stated she spoke to the wound care physician and discussed the resident 's history of urinary tract infections, and that she was hesitant to insert a Foley due to this history. She stated that the wound was not at a point that it was going to be an issue. It was [MEDICAL CONDITION] at the time, and she decided to monitor the wound, and assess the wound on her next visit. When asked about documentation, the ARNP stated that she did not document it, it was just a conversation. She did not feel that the Foley was warranted at that time and she was trying to be very conservative. The ARNP stated that the wound was deteriorating, and she decided to go with the Foley today, 2/27/2020. The ARNP stated that the Foley was not discussed on Tuesday, (2/25/2020). She added that the wound care nurse notified her about the Foley either yesterday 2/26/2020 or today 2/27/2020. On 02/27/20 at 3:41 PM, the wound care physician stated, that generally he documented his recommendation(s) in his notes, but the PCP has the final decision making. The wound care physician stated that he was aware that the ARNP tried [MEDICATION NAME], to try to control the resident's urine, and was aware of the concern with inserting the Foley. He was made aware of this on Tuesday 2/25/2020. The wound care physician stated that he did not recall speaking directly about the resident with the ARNP on [DATE], 2/11/20, or 2/18/20. The Wound care physician stated that the resident's wound was constantly getting wet, and he felt that the Foley would have helped /contributed to the healing of the resident's wound. On 2/27/20 at 4:52 PM, an interview was conducted with the Administrator, the DON, the Captiva/Key West unit manager, (UM) and the wound care nurse. The resident's wound care notes, physician orders, progress notes, and the ARNP notes were reviewed. The wound care nurse stated that the ARNP gave her a verbal order for [MEDICATION NAME] for resident #7. She said, she usually entered it into the electronic medical record. I don't know what happened, I could have been distracted, I do not know why I did not put it in. When asked about the facility's process regarding review of the resident's care to ensure adequate and correct implementation of orders, the wound care nurse said she did not know who followed up. The Captiva/Key West UM stated that she did not go on wound rounds with the wound care physician, and did not review the wound care notes. She stated that she depended on the wound care nurse to keep her informed regarding the resident's wound care. The DON stated that the wound care physician spoke with the ARNP about the resident's wound on 2/11/20. It was a verbal discussion related to the [MEDICATION NAME] and it was not documented. The DON stated that the ARNP saw the wound but there was no documentation provided of the wound assessment. When asked about communication between the PCP/ARNP, the wound physician, and the facility, the facility could not explain how both the ARNP, and the wound care physician thought the resident was on [MEDICATION NAME], when the [MEDICATION NAME] was never ordered. The Administrator stated that the expectation was for the physician/ARNP to document when they saw residents. On 02/27/20 at 5:44 PM, the Medical Director (MD) stated that he was aware of the concern with wound care for resident #7. He was aware that the wound care physician recommended a urinary catheter, and the ARNP did not was not in favor. The MD stated that [MEDICATION NAME] would not have had any effect on the pressure ulcer and there were no guidelines for the use of [MEDICATION NAME] for pressure ulcers. The MD stated that [MEDICATION NAME] would control episode of urine, but not the volume. He stated the resident would still need the same care. The MD was informed that both the wound care physician, and the ARNP believed that the resident was on [MEDICATION NAME], when in fact the [MEDICATION NAME] was never ordered. The MD stated, that he tried to keep communication open, but there were areas for improvement.

Based on interview and record review, the facility failed to provide adequate supervision, prevent involuntary seclusion, and implement approaches to ensure safety while preserving the individuality and preferences for 1 of 4 sampled residents (#261). These failures contributed to the elopement of resident #261, placing him at risk for serious injury/impairment/death. On 2/11/17, the actions/inactions of the facility staff compounded the situation in which resident #261 eloped from the facility at approximately 1:38 PM, via the front door. The resident was missing for about 3 hours and his whereabouts were unknown by staff. The resident was found 0.3 miles, west of the facility on a grassy area between a six lane busy highway and the parking lot of a convenience store. The failure to provide needed supervision and accurately assessing the resident's needs and preferences resulted in the resident's elopement and subsequent Past non-compliance at the Immediate Jeopardy level, identified as occurring on 2/11/17 and removed as of 8/03/17, before exit. Findings: Resident #261 was a [AGE] year-old resident who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Upon admission, the facility staff interviewed resident #261 and assessed that he was cognitively impaired as evidenced by the Minimum Data Set ((MDS) dated [DATE]. The resident initially received speech therapy with a certification date from 10/18/17 to 2/04/17. On the Speech Therapy Evaluation and Treatment Plan, speech therapist V noted the resident's Allen Cognitive Level score was 4 out of 6. The Allen Cognitive Level Screen (ACLS) is a test that evaluates the ability of someone to make decisions, function independently, safely perform basic skills, and learn new abilities A score of 5.8 means that in general, you are able to function quite well independently in your own home A score of less than 5.8 indicates that you will likely need or benefit from some type of assistance in daily living tasks. (verywell.com). The therapist noted that the resident was capable of understanding yes and no questions but had severe expressive language and communication abilities. There was no evidence in the medical record to explain how the staff assessed the resident's cognitive status for the MDS assessment since the resident could not be understood/interviewed. The resident was placed on the facility's locked unit with other residents with impaired cognition upon admission to the facility in October, 2016. On 8/21/17 at approximately 11 AM, the admissions coordinator stated resident #261 was admitted to the locked unit because he was found outside at the previous nursing home in 2016. The admissions coordinator did not provide any evidence that the resident had actually eloped from the previous facility. The admissions coordinator stated there was no written assessment but the director of nursing (DON) reviewed the resident's information. The admissions coordinator stated that based on the resident's history, we determined that he should be on the locked unit rather than in the unlocked unit. A social service note, dated 11/10/16, indicated that a care plan meeting was held but the resident/family did not attend. The resident was noted to need constant supervision for safety Psych/Psychology consults in place; monitored for elopement risk On 11/11/16, the resident was transferred from the locked unit to an unlocked unit. On 8/21/17 at 1:05 PM, the unit manager (UM) stated the speech therapist recommended that the resident should be transferred out of the locked unit during the interdisciplinary team (IDT) meeting and the physician agreed. The facility could not provide a physician's orders [REDACTED]. The quarterly MDS, dated [DATE], noted that the resident had unclear speech, that he was sometimes understood, and that he usually understood others. The resident scored a 3 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was severely impaired. This MDS also noted that the resident had wandering behavior 4-6 days during this assessment period. On 1/30/17, the UM assessed that the resident continued to be an elopement risk. Review of the Elopement Care Plan noted only two approaches to prevent the resident from eloping from the facility. The first approach was to Offer reassurance and support as needed. The second approach was Reorientation to person, place and time as needed. However, the Elopement Care Plan was not updated when the resident transferred off the locked unit. The Elopement Care Plan did not include any individualized or new approaches even though the resident's wandering had increased since admission. On 8/21/17 at 5:15 PM, the administrator recalled the events on 2/11/17. He stated that 2/11/17 was a Saturday and he was the manger on duty. At approximately 11 AM, a nurse informed him that resident #261 had exited the front door and was outside the facility. The administrator stated the resident was in his wheelchair, on the sidewalk, under a tree. When the administrator asked the resident what he was doing outside, the resident gestured to the tree and stated, Shade. The administrator instructed the resident to come inside and suggested that a wander bracelet be placed on him. He stated the weekend supervisor was in agreement and the resident was informed. The resident did not want to wear the wander bracelet but finally agreed. When the weekend supervisor applied the bracelet device, the resident again refused but they were able to coax the resident into accepting the wander bracelet. The resident sighed and held out his left wrist and the device was applied. When asked what was the risk/danger of the resident sitting outside under the tree, the administrator could not provide an answer other than it was not the resident's usual routine. The administrator could not provide an answer when asked why the resident could not be supervised by a staff member while outdoors. The facility and the administrator neglected the resident's preference to enjoy the outdoors. On 2/11/17, the resident was in his wheelchair on the sidewalk in front of the facility and the Orlando Florida weather was 80 degrees Fahrenheit (National Oceanic & Atmospheric Administration). Later that afternoon on 2/11/17, the administrator said he left the facility and at 4:36 PM, he received a phone call from the receptionist that resident #261 had exited the building and was located near the convenience store by an off-duty employee. The resident was brought back to the facility by the nursing supervisor. The administrator returned to the facility and the supervisor informed him that the resident had removed the wander bracelet. The administrator stated that another wander bracelet was applied and the resident was then placed on the locked unit. The facility neglected to assess the resident upon return to the facility to determine if he needed to be on the locked unit or if increased supervision would benefit the resident. Review of the resident's Activity Care Plan, dated 11/12/16, noted that the resident was capable of choosing his activities. The care plan indicated that the resident preferred activities that included spending time outside and people watching. The admission MDS, dated [DATE], noted that it was very important to the resident to go outside to get fresh air when weather permitted. The resident was subjugated to wear a wander bracelet even though the facility could not justify it's use. On 8/22/17 at 1:30 PM, the weekend supervisor, licensed practical nurse (LPN) G stated that she worked on 2/11/17. On that day, she said the administrator informed her that resident #261 was outside the facility on the front patio. She stated she was instructed by the administrator to apply a wander bracelet on resident #261. When asked if it was her clinical judgement to apply the wander bracelet, she stated she was not familiar with the resident. She said the administrator instructed her to apply the wander bracelet and If my boss asks me to do something, I do it. LPN G neglected to review the resident's care plans and determine that he could still enjoy the outdoors with the possibility of staff supervision. LPN G recalled the resident's elopement. She was not aware that the resident had left the facility. She could not explain how the resident got out of the facility and how staff did not know his whereabouts for almost 3 hours. She said she received a call from a staff member in the rehabilitation department that resident #261 was observed near the convenience store. She stated that she went to the convenience store and brought the resident back to the facility by an off-duty employee. Upon return to the facility, she noted that the resident was not wearing the wander bracelet on his left wrist she had applied in the morning. She placed a new wander bracelet on the resident and placed him on the locked unit. She stated that the locked unit was for the resident's safety but confirmed she did not discuss this measure with the resident's physician. She confirmed that she did not receive a physician's orders [REDACTED]. LPN G stated she could have utilized staff to supervise the resident closely or implement one to one supervision but she did not think of it at the time. LPN G stated that she briefly spoke with the resident as to why he left the facility. She said he was upset that we placed a wander bracelet on him and he wanted to get cigarettes. Review of the incident/accident logs from 1/01/17 to 7/24/17 did not contain any entries relating to resident #261's elopement. On 7/25/17, the administrator indicated that the facility did not have any incidents of elopement. He identified that resident #261 was missing on 2/11/17. On 7/26/17 at 11:53 AM, the director of nursing (DON) stated that the facility did not have actual elopements but there was a near miss sometime recently. The facility's social service manager (SSM) was responsible for Abuse/Neglect, and the administrator was the risk manager. On 7/26/17 at 2:50 PM, the SSM stated that resident #261 had an unauthorized absence on 2/11/17. She defined unauthorized absence as, When someone leaves the building without informing anyone. When asked why resident #261 was determined to be an unauthorized absence versus and an elopement, she said, That was determined by the administrator, who is the risk manager. There were 2 definitions on the facility's Elopement Policy, dated 10/25/16: 1. Exit - An attempt to leave the premises which is directly observed by staff or observed by staff on the facility's property or where a previously identified wanderer attempts to leave the premises and sets off the wander guard system, who is immediately returned to the facility without harm. 2. Elopement - When a cognitively impaired resident is found outside the facility property, without the knowledge of staff, or resident identified as missing from the facility. The facility's Elopement Policy failed to identify elopement as a sentinel event and a Federal reporting requirement. On 8/21/17 at 2:07 PM, the two MDS Coordinators stated that the social service assistant (SSA) completed the cognitive section of the MDS. She said she interviewed resident #261 to determine his Brief Interview for Mental Status (BIMS). The coordinators stated the SSA incorrectly coded the resident's cognition on the MDS on 1/27/17. At 2:54 PM, the SSM joined the meeting. The MDS coordinators stated that all MDS assessments had to be modified because the resident could not be interviewed, and the SSA coded the MDS incorrectly. The coordinators stated that the SSA should have completed the Staff Assessment for Mental Status instead of the resident interview. The SSM stated that the resident's cognition fluctuated, and that it was difficult to understand him because of his [MEDICAL CONDITION]. The staff confirmed that all the MDS modifications were done after the resident had eloped from the facility on 2/11/17. Review of the modified MDS assessments for both the 5-day assessment and the quarterly MDS noted that the resident was classified as modified independent with cognitive skills for decision making. This means the resident's cognition was not severely impaired but the resident has difficulty in new situations. The MDS coordinators said the MDS modifications were done because they were, just doing what we were told to do. Four days after the elopement, on 2/15/17, the resident was seen by the doctor for the first time since the elopement. The doctor noted that the resident had a speech impediment and some [MEDICAL CONDITION]. The resident could answer yes/no questions and follow directions. The doctor noted that the resident was totally competent and did not need to be on the locked unit. This was totally contradictory to the assessment in November 2016, when the same doctor deemed the resident to be incapacitated to make medical decisions. The facility neglected to accurately assess the resident at admission, and the resident was placed on the locked unit. The resident's cognition was not accurately determined until after the elopement, so that his new cognition status would only enhance the facility's narrative that an elopement did not occur. The facility neglected the resident's right to choose outdoor activities that were noted to be very important to him. The facility neglected to identify the resident's exodus as an elopement and investigate the root cause. The facility failed to identify the lapse in their assessment process that led to a wander bracelet placement and the resident's unhappiness about wearing the bracelet. The facility neglected to create an effective communication system with the resident which would have determined if the resident was enjoying the outdoors or actively trying to elope from the facility on the morning of 2/11/17. Past non-compliance at the Immediate Jeopardy level was identified as occurring on 2/11/17 and removed as of 8/03/17, before exit. * The facility's Corrective Actions revealed that staff received education on neglect on 7/29/17 through 8/03/17. The education consisted of the definition of neglect, meaning a failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. The education information presented included the identification of types of neglect which include failure to provide nutrition, supervision, medication, and medical care. Staff education included the process of investigating and reporting neglect. * Facility process changes included Nurse Management Team walking rounds at shift change, visualizing and identifying all residents and their needs on their assignment. If a resident is not located in his/her room, Upon initial rousing, it is expected for both on-coming and off-going staff to round until all residents have been visualized or their whereabouts known. The front door will remain locked twenty four hours a day. * An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted on 7/29/17 and 7/30/17. The policy for Abuse/Neglect was reviewed and the Federal One Day report was filed on 8/08/17.

Based on interview and record review, the facility failed to accurately assess 1 of 4 sampled residents at risk for potential elopement for cognition and safety (#261). This contributed to resident #261 eloping from the facility, and placing him at serious risk for serious injury/impairment/death. The resident was missing for approximately 3 hours without staff aware of his whereabouts. The facility failure to accurately assess the resident resulted in Past non-compliance at the Immediate Jeopardy level, identified as occurring on 2/11/17 and removed as of 8/03/17, before exit. Findings: Resident #261 was a [AGE] year-old resident who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS), dated [DATE], noted that the resident had clear speech indicating the resident spoke with distinct, intelligible words. The resident sometimes could make himself understood and sometimes understood others. The facility staff used the Brief Interview for Mental Status (BIMS) to assess the resident's cognition. The resident's BIMS Summary Score was a 3, indicating the resident's cognition was severely impaired. The MDS noted that the Staff Assessment for Mental Status should not be conducted. The resident was interviewed for his activity preferences. The MDS noted that going outside to get fresh air when the weather was good, was very important to the resident. The MDS noted that the resident did not have any wandering behavior. Upon admission to the facility, the resident was placed on the facility's locked unit with other residents who had impaired cognition and wandering behavior. On 8/21/17, the admissions coordinator stated that resident #261 was transferred to this facility from one of their sister facilities. She stated he was referred to the locked unit because the resident was found outside at the previous facility. When asked, if there was an assessment that indicated that the resident required a locked unit, the admissions coordinator indicated that there was no written assessment but the information was reviewed by the director of nursing (DON). The admissions coordinator stated that based on the resident's history, we determine whether he should be on the locked unit or general population. A review of the 10/27/16 Elopement Assessment noted that the resident was at risk for elopement. Upon admission, the resident was treated by speech therapy from 10/28/16 to 2/04/17. The Speech Therapy Evaluation & Treatment Plan, signed 11/13/16, noted that the resident was referred to speech therapy due to exacerbation of cognitive impairment, [MEDICAL CONDITION], cognitive-communicative deficits. The resident had a recent hospitalization on [DATE] with a new onset of severe [MEDICAL CONDITION] and right [MEDICAL CONDITION]. The resident had a Middle Cerebral Artery (MCA) stroke with MCA occlusion. The therapist noted that the resident was capable of understanding Yes and No questions but had severe expressive language and communication abilities. Speech therapist V described the resident's verbal expression as anomia. Anomic [MEDICAL CONDITION] (anomia) is a type of [MEDICAL CONDITION] characterized by problems recalling words, names, and numbers. (wikipedia.org). There was nothing in the medical record to support how the facility staff conducted a BIMS at admission, since the resident could not be understood/interviewed. Despite the resident's poor communication skills, speech therapist V noted that the resident had an Allen Cognitive Level of 4 out 6. The Allen Cognitive Scale is one of several tools used to create a personalized recommendation for Care used to identify a resident's abilities, monitor change over time, help plan treatment and guide placement Level 4 is defined as physically independent with daily care, but needs assistance to initiate or monitor quality of care; needs increased assistance with all cognitive skills; memory challenges have increased; may not anticipate possible dangers or consequence; success in note with structure and repetition; need assistance to live in community. (emeraldcrest.com). Documentation from social services staff, dated 11/10/16, read, Care plan meeting held today. Resident/family were unable to attend He is on therapy case load for [MEDICAL CONDITION] and gait training he needs constant supervision for safety Psych/Psychology consult in place; monitored for elopement risk On 11/11/16, the resident transferred from the locked unit to room [ROOM NUMBER]. The facility staff could not provide an assessment that the resident was no longer an elopement risk. Review of the resident's Elopement Care Plan, dated 10/28/16, noted only two approaches that would prevent the resident from eloping from the facility. The first approach was to Offer reassurance and support as needed. The second approach was, Reorientation to person, place and time as needed. However, the Elopement Care Plan was not updated with added approaches, such as increased supervision when the resident was transferred off the locked unit. On 11/29/16, the resident was determined to be Incapable of Making Medical Decisions by his physician. The resident's estranged wife was the resident's health care proxy. The quarterly MDS, dated [DATE], noted the resident had unclear speech, and that he sometimes is understood but he usually understands others. The resident scored a 3 on the BIMS, which indicates that the resident's cognition was severely impaired. This MDS also noted that the resident refused care daily and had wandering behavior 4-6 days during the assessment period. On 1/30/17, the UM assessed the resident and determined that he was an elopement risk. Review of the resident's care plan did not reveal any new approaches on the Elopement Care Plan. The staff did not address the resident's wandering behavior. The resident's Activity Care Plan, initiated on 11/12/16, noted that the resident was capable of choosing his activities. The care plan indicated that the resident's preferred activities included spending time outside and people watching. On 8/21/17 at 1:05 PM, the unit manager (UM) stated that shortly after admission, the speech therapist recommended that the resident be transferred out of the locked unit during the interdisciplinary (IDT) meeting and the doctor agreed. At the time of the survey, the facility staff could not provide a physician's orders [REDACTED].#261 could be transferred off the locked unit. On 8/21/17 at 1:05 PM, the UM stated she was not made aware of resident #261's elopement on Saturday, 2/11/17 until the morning meeting that was 2 days after the incident, Monday 2/13/17. She stated she was informed that the resident was outside the facility on the morning on 2/11/17, sitting on the front patio. She added that she suggested one to one (1:1) staff supervision of the resident, and was not aware that the resident had eloped to the convenience store that same day until she read the 24 hour report on Monday morning, 2/13/17, two days after the incident. She stated she was aware that the administrator was dealing with the resident on 2/11/17 and that Corporate personnel were involved. She could not explain why 1:1 or close supervision of the resident was not implemented. She stated she was not part of the decision to place the resident on the locked unit. On 8/21/17 at 2:07 PM, the two MDS coordinators stated the social service assistant (SSA) completed sections B, C, D, E & Q on the MDS. The SSA was the staff person who interviewed resident #261 for the BIMS. The MDS coordinators stated the SSA completed the sections on the MDS incorrectly. At 2:54 PM, the social worker (SW) joined the meeting. The MDS coordinators stated that all of the MDS assessments had to be modified because the SSA should not have done the BIMS because the resident was not interviewable. The coordinators stated the SSA should have completed the Staff Assessment for Mental Status instead of the BIMS. The SW stated the resident's cognition fluctuated, and it was difficult to understand him because of his [MEDICAL CONDITION]. [MEDICAL CONDITION] is the loss of ability to understand or express speech, caused by brain damage. ([MEDICAL CONDITION].org). The staff confirmed that all MDS modifications were done after the resident had eloped from the facility. Review of the modified MDS for the admission and quarterly assessments noted the resident's cognition as Modified Independent. This would mean the resident is not severely cognitively impaired. The MDS coordinators modified the MDS to indicate the resident did not elope but chose to leave the facility. On 8/21/17 at 5:15 PM, the administrator stated that he was the manager on duty (MOD) on 2/11/17. At approximately 11 AM, a nurse informed him that resident #261 had exited the front door and was outside the facility. The administrator stated the resident was sitting in his wheelchair, on the sidewalk, under a tree. When the administrator asked the resident what he was doing outside, the resident gestured to the tree and stated, Shade. The administrator instructed the resident to go back into the facility and suggested a wander bracelet be placed on him. He stated the weekend nurse supervisor was in agreement with the wander bracelet. When the weekend nurse supervisor attempted to apply the wander bracelet, the resident refused. The administrator stated they were able to coax the resident into accepting the device. The resident sighed, held out his left wrist, and the wander bracelet was applied. When asked what the risk/danger was of the resident sitting outside under the tree, the administrator could not provide an answer other than it was not the resident's usual routine. When asked if there was an assessment that indicated the resident needed a wander bracelet, the administrator replied, Clinical Judgment. The administrator indicated that the UM and staff development nurse were part of of the decision to put the wander bracelet on the resident. The administrator stated he left the facility later that afternoon and received a call at 4:36 PM from the receptionist that resident #261 had left the building and was located near a convenience store. He said the nurse supervisor brought the resident back, and he, the administrator, returned to the facility. The administrator stated the resident had removed the wander bracelet, and staff was unable to determine how this was done. The resident was able to exit through the front door while the receptionist was on a break. When asked if the facility relied on the wander bracelet for keeping the resident safe, the administrator could not provide an answer. The resident was given another wander bracelet, and was placed on the locked unit. The administrator reiterated that he consulted with the UM and staff development nurse, and it was a Clinical Judgement to put another wander bracelet on the resident and place him on the locked unit. On 8/22/17 at 1:30 PM via telephone, the weekend supervisor, licensed practical nurse (LPN) G revealed that she worked a double shift on 2/11/17. She stated that she was made aware by the administrator in the morning of 2/11/17 that resident #261 was outside on the front patio. She said she was instructed by the administrator to apply a wander bracelet on the resident. When asked if it was her clinical judgement to apply the wander bracelet, she stated that she was not familiar with the resident. She was asked by the administrator to apply wander guard, and said, if my boss asks me to do something, I would do it. She said the second time, she received a call from a rehab staff member informing her that resident #261 was observed near the convenience store. She said she was not aware that the resident was missing until the call. She stated she went to bring the resident back. He was in his wheelchair on the sidewalk next to the busy 6 lane highway. Upon return to the facility, she noted that he did not have his wander bracelet on. She stated that she had applied the bracelet in the morning on his left wrist. She placed a new wander bracelet on the resident and placed him on the locked unit. She could not explain what happened to the previous wander bracelet, and did not ask the resident what happened to it. She called the administrator and left a message with the service for the physician to call back but did not speak with the him. She said she briefly spoke to the resident about why he left the facility. He said he was upset that we had placed a wander bracelet on him and he also wanted to get cigarettes from the convenience store but he did not have any money. She said, He was very upset about the wander bracelet and he did not want it applied, saying 'No' but we were able to coax him into it. She could not provide an answer when questioned as to why the wander bracelet was applied when the resident clearly did not want it. She stated it was for his safety but could not answer if the resident was being supervised. She did not answer when asked if the wander bracelet was used as a substitute for supervision of the resident. On 8/22/17 at 2:10 PM, the staff developer stated she was not involved in the decision to place the resident on the locked unit. She added that the administrator had only texted to inform her that the weekend supervisor had started re-educating the staff about elopement. On 8/22/17 at 3:15 PM, the speech therapy notes were reviewed with speech therapist W. She stated she did not treat the resident, and that speech therapist V, who initially treated resident #261, no longer worked at the facility. She stated that cognitive status can be difficult to assess with residents who are aphasic. She stated that dementia can be easily misdiagnosed with [REDACTED]. She indicated at that score, the resident would have moderate cognitive impairment. She indicated that an assessment that requires verbal response from the resident, such as a BIMS, would not be a fair test for resident #261. She indicated that an ACL assessment would be a more effective tool to utilize for resident #261. The ACL was available but the MDS and social service staff did not utilize the speech therapist to assist with determining the resident's cognitive level. She stated that the speech therapists are not routinely asked to help social services to complete the BIMS. The resident was assessed/evaluated by speech therapist V on 2/13/17, which was two days after the elopement. The resident had an ACL score of 6 out of 6, meaning there were no cognitive deficits. Speech therapist W stated that ACL and dementia have an inverse relationship. She stated with an ACL of 6, the resident could still have dementia but it would be so slight that anyone who knows the resident, such as family/friends, would not be able to identify any signs of dementia. Speech therapist W also stated that going from a 4 to 6 on the ACL was not very common. Per the resident's medical record, the resident was seen by the physician for the first time since the elopement on 2/15/17, four days after the elopement. He noted that the resident had a speech impediment and some [MEDICAL CONDITION]. He noted that the resident can answer yes/no questions and follow directions, was totally competent, and did not need to be on the locked unit. The resident was discharged from the facility to home with family on 3/04/17. Review of the discharge MDS, dated [DATE], noted the resident's [DIAGNOSES REDACTED]. The facility's failure to accurately assess resident #261's cognitive status and implement methods so that the resident could effectively communicate with staff compounded the situation that led to the elopement. The resident was removed from the locked unit in November 2016, The quarterly MDS, dated [DATE], noted the resident had wandering behavior 4-6 days during the assessment period. On 1/30/17, the UM assessed the resident and determined that he was an elopement risk. The facility did not implement any approaches to mitigate the resident's wandering behavior. On 2/11/17, the resident exercised his right to go outside and sit under a tree, and a wander bracelet was placed on him. The facility failed to recognize the resident's preference for being outside, failed to determine if he was truly trying to leave the facility or if he was just following his activity care plan. Placing the wander bracelet on the resident without an assessment only compounded the situation, and the resident to eloped. After returning to the facility, the staff failed to assess the resident, placed another wander bracelet on him, and put him on the locked unit. The facility failed to determine if the resident could safely enjoy the outdoors with or without staff supervision. Past non-compliance at the Immediate Jeopardy level was identified as occurring on 2/11/17 and removed as of 8/03/17, before exit. * The facility conducted an ad hoc Quality Assurance Performance Improvement (QAPI) meeting on 7/29/17 and held weekly Quality Assurance (QA) meetings to address the elopement issue and imitated an action plan. The committee reviewed staff training and education, reception coverage, elopement drills, elopement assessments and care plans, missing resident books and audits. Re-education regarding elopement and supervision was provided to the facility staff starting on 7/29/17-8/3/17 including 73 nursing assistants, 40 licensed nurses and 65 departmental personnel. Newly hired staff will be educated regarding elopement and supervision upon hire. * On 7/27/17, all 102 residents' elopement risk assessments were re-evaluated and on 7/30/17 all residents' cognitive status was validated along with mobility status. Of the 102 residents evaluated, 16 residents were physically able to leave the facility. * On 8/22/17 at 3:15 PM, speech therapist W stated that she has in-serviced the staff on [MEDICAL CONDITION] and cognitive impairment. She stated the best practice would be for a speech therapist to assess residents with [MEDICAL CONDITION] and determine if a BIMS can be done. She stated dementia staging is done on a weekly basis of all new admission or referrals with changes in resident condition.

Based on observation, interview and record review, the facility failed to provide adequate supervision and safe environment for 1 of 4 residents at risk for actual and potential elopement (#261). These failures contributed to the elopement of resident #261 placing him at risk for serious injury/impairment/death. The failure to provide adequate supervision and safe environment resulted in resident's elopement and subsequent Past non-compliance at the Immediate Jeopardy level, identified as occurring on 2/11/17 and removed as of 8/03/17, before exit. Findings: Cross reference to F223, F272, F490 and F520. Resident #261 was a [AGE] year old male with vascular dementia related to multiple cerebral vascular accidents, (strokes), [DIAGNOSES REDACTED], hemiparesis, aphasia, muscle weakness, and hypertension. He was admitted on [DATE] from another long term care facility and was placed on the locked unit due to a history of exit seeking behavior from the transferring facility. He was relocated to a non-locked unit on 11/11/16. An activity care plan dated 11/12/16 identified that resident preferred spending time outdoors and enjoyed people watching. He had been deemed incapable of making medical decisions on 11/29/16. His primary mode of locomotion was via walker or wheelchair. The Minimum Data Set (MDS-used to complete a comprehensive assessment of each resident) with assessment reference date (ARD) of 1/27/17 revealed that he had unclear speech and was sometimes understood, wandered 4-6 days per week, had severely impaired cognitive skills for decision making, and required 1 person extensive assistance with walking. On 2/11/17, the resident was found sitting outside on the front patio of the facility and instead of assessing the resident for possible risk and increasing supervision, the facility placed a wander bracelet on the resident contrary to his wishes. Later that day the resident exited the facility due to lack of supervision and angry about having a wander bracelet. He pushed his wheelchair over curbs, across a street and traveled 0.3 miles from the facility and was spotted in a parking lot of a convenience store near a busy 6 lane highway. He was not discovered missing until almost three hours later when an off duty staff member spotted him as she was driving on the busy 6 lane highway and informed the facility. He was brought back to the facility and again subjected to a wander bracelet and again placed on a locked unit. Interviews with the administrator, unit manager and nursing supervisor failed to identify how the resident was being supervised to prevent him from leaving the facility and potentially being seriously injured/impaired/death. The facility could not explain how the resident was missing for approximately 3 hours without staff knowledge of his whereabouts. It was evident that the facility relied on the wander bracelets to alert them when a resident was attempting to leave the facility in place of maintaining close supervision of the residents at risk for elopement. On 2/11/17 at 1:38 PM, resident #261 left the facility via the front door. The whereabouts of resident # 261 were unknown for approximately 3 hours until he was located 0.3 miles from the facility. The resident was observed by an off duty staff member who was driving by on a busy 6 lane highway. The staff member telephoned the facility to inform them that she saw resident #261 in the parking lot of a convenience store near the busy 6 lane highway. A Risk for Elopement Assessment, dated 1/30/17, noted that the resident was at risk for elopement. A physician order, dated 2/11/17, reflected that staff apply safety bracelet related to elopement risk. The comprehensive care plan, dated 10/28/16, noted that resident #261 was at risk for elopement with the goal that the resident will not be off facility property without supervision. There were no interventions listed on how or how often to supervise the resident to prevent elopement. The care plan was not updated post elopement on 2/11/17 to include any customary routines or approaches for individualized supervision to ensure a safe environment or any interventions to prevent elopement. The resident was also identified at risk for falls due to decline in functional status and associated physical impairments. The interventions included cue for safety awareness, keep environment clear and safe, and provide assistance with transfers and ambulation. A telephone interview with the resident's primary care physician on 7/28/17 at 1:44 PM revealed that the resident's elopement was an unsafe situation because he was missing for almost 3 hours without staff knowledge of his whereabouts. He stated that if the resident wished to be outside or get cigarettes, staff should accompany him. There was no documentation indicating the physician was contacted when the resident eloped. There was no physician order to place the resident on the locked unit after he was brought back to the facility. On 7/29/17 at 12:40 PM, certified nursing assistant (CNA) N revealed that she was assigned to care for resident #261 on 2/11/17. She stated she did not do walking rounds at the start of her shift with the off going CNA at 7 AM. She saw resident #261 in bed, and said, I usually get him up a little later. He ate his lunch in his room and then left his room via wheelchair to get coffee and sit in front of the activity room. The last time she saw him was between 12 PM and 1 PM. She was unable to state how often residents with wander bracelets were to be checked but stated she, always checked on her people. On 8/21/2017 at 1:05 PM, the unit manager said that she was contacted by the administrator when the resident was observed sitting out on the front patio. She had suggested 1:1 staff observations of the resident. She said she was not aware that the resident had eloped to the convenience store until she read the 24 hour report on Monday morning, 2 days after the incident. She stated that she was aware the administrator was dealing with the resident on 2/11/17 and corporate was involved. She could not explain why 1:1 or close supervision of the resident was not implemented rather than relying on the wander bracelet to keep the resident safe. She also could not explain how often residents with wander bracelets were to be observed other than routinely. On 8/21/17 at 5:15 PM, the administrator revealed that resident #261 had exited the facility on 2/11/17 at approximately 11 AM. He stated that he was at the facility as the manager on duty on 2/11/17 and a nurse informed him that resident #261 was outside the front door. He could not explain how the resident had managed to exit the front door when there was a receptionist on duty at the front door. He said that the resident was sitting in his wheelchair on the sidewalk under a tree and when asked what he was doing outside, he gestured to the tree and stated, shade. The administrator stated he asked the resident to come inside and suggested that a wander bracelet be placed on him. He said the weekend supervisor was in agreement and the resident was informed. The resident did not want a wander bracelet but finally agreed. When the weekend supervisor applied the bracelet, the resident again refused but they were able to coax the resident into accepting the wander bracelet. The resident sighed and held out his left wrist and the device was applied. When asked what was the risk/danger of the resident sitting outside under the tree, the administrator could not provide an answer other than it was not the resident's usual routine. The administrator could not provide an answer when asked why the resident could not be supervised by a staff member while outdoors. A review of the admission MDS, dated [DATE], noted that it was very important for the resident to go outside to get fresh air. The administrator stated that he received a telephone call later the same day on 2/11/17 from the receptionist at 4:36 PM that the resident had left the building and was located near the convenience store. He was brought back to the facility by the nursing supervisor. The administrator returned to the facility and was informed by the supervisor that the resident had removed his wander bracelet but she could not determine how he did this. The administrator stated that the resident was able to exit the front door when the receptionist went on her break and the front door was unattended. She did not have a replacement at reception when she left for breaks. When asked how often the resident was observed by staff as he was an elopement risk, the administrator could not provide an answer. When asked if the facility relied on the wander bracelet rather than close supervision for keeping residents safe, he could not provide a justifiable answer. The administrator stated that he searched for the bracelet but could not find it. He could not provide any documentation indicating any investigation was done of the elopement incident including an incident report. He said the resident was angry about wearing the wander bracelet and that is why he left the facility. He stated that a decision was made to place the resident on the locked unit. When asked how the decision was made, the administrator stated that it was clinical judgement. When asked whose clinical judgement, he stated that it was a decision made by the unit manager and staff developer. On 8/22/17 at 1 PM, the administrator showed the route which was captured on camera that the resident took when he left the facility property. He stated that the camera captured the resident pushing his wheelchair over a curb in the parking lot onto a grassy area leading away from the facility at 1:38 PM on 2/11/17. An observation was conducted of the path to the convenience store and the surrounding area where the resident was located. The resident had to push his wheelchair over a 6 inch curb, then transverse over uneven grassy areas onto a parking lot of a strip mall then cross a 2 lane street onto the busy parking lot of the gas and convenience store. He was found sitting in his wheelchair in a grassy area in front of the convenience store approximately 30 feet from a busy 6 lane divided highway with additional right and left turn lanes. The speed limit on the highway was 45 miles per hour. The resident was identified at risk for falls and had to push his wheelchair over large curbs, uneven pathways and was in close proximity to the busy highway and cars entering and exiting the gas station/convenience store. On 8/22/17 at 2:10 PM, the staff developer stated that she was not involved in the decision to place resident on the secure unit. She said the administrator had texted her on 2/11/17 informing her that the weekend supervisor had started education on resident elopement. On 8/22/17 at 2:30 PM, the occupational therapy assistant revealed that she was off duty on 2/11/17. She stated she was driving north on the busy highway on 2/11/17 in the afternoon between 4 PM and 4:30 PM, heading toward Orlando. She stated there was a lot of traffic, and when she glanced toward the convenience store, she spotted resident #261 sitting in his wheelchair near an open area of the hedges. She stated she recognized him immediately as he had a distinguishable face, including a beard. She telephoned the facility on her mobile phone and spoke to the therapy department. She said, I informed the therapist that I had observed (resident #261) in front of the convenience store and asked him to immediately inform the nurse. On 8/22/17 at 1:30 PM, telephone interview with the weekend supervisor, licensed practical nurse (LPN) G revealed that she worked a double shift on the weekend of 2/11/17. She stated that she was made aware by the administrator in the morning of 2/11/17 that resident #261 was outside on the front patio. She said she was instructed by the administrator to apply a wander bracelet on the resident. When asked if it was her clinical judgement to apply the wander bracelet, she stated that she was not familiar with the resident. She was asked by the administrator to apply the wander bracelet, if my boss asked me to do something, I do it. She said the second time, she received a call from a rehab staff member, informing her that resident #261 was observed near the convenience store. She said she was not aware that the resident was missing. She stated that she went to bring the resident back. He was in his wheelchair on the sidewalk next to the busy 6 lane highway. Upon return to the facility, she noted that he did not have his wander bracelet that she had applied in the morning on his left wrist. She placed a new wander bracelet on the resident and placed him on the locked unit. She could not explain what happened to the previous wander bracelet, and did not ask the resident what happened to it. She called the administrator and left a message with the physician's service to call back but did not speak with the doctor. She said she briefly spoke to the resident about why he left the facility. She said he was upset that we had placed a wander bracelet on him and he also wanted to get cigarettes from the convenience store but he did not have any money, He was very upset about the wander bracelet and he did not want it applied, saying, no, no but we were able to coax him into it. She could not provide an answer when asked why the wander bracelet was applied when the resident clearly did not want it. She stated it was for his safety but could not answer if the resident was being supervised or how often residents with wander bracelets were to be observed. She did not answer when asked if the wander bracelet was used a substitute for supervision of the resident. She could not provide an answer when asked how no one was aware that the resident was missing for almost 3 hours. The Resident Elopement Policy, revised 10/25/16 read, The facility strives to provide a safer environment and implements preventive measures to minimize elopement. Elopement-When a cognitively impaired resident is found outside the facility's property, without the knowledge of staff, or resident identified as missing from the facility Upon return of the resident to the facility, the Director of Nursing or charge nurse will Contact the attending physician, report findings and conditions of the resident, and follow the physician's orders complete and file an Incident/Accident Report Investigate how the resident was attempting to exit. Update the resident's care plan with interventions for elopement prevention. Interviews conducted with the facility staff showed there was no protocol noting how often residents with wander bracelets were to be observed to prevent potential elopement. Past non-compliance at the Immediate Jeopardy level was identified as occurring on 2/11/17 and removed as of 8/03/17, before exit. * The facility's Corrective Actions revealed that staff received education on supervision from 7/29/17 through 8/03/17. * The facility conducted an ad hoc Quality Assurance Performance Improvement (QAPI) meeting on 7/29/17 and held weekly QA meetings to address the elopement issue and initiated an action plan. The committee reviewed staff training and education, reception coverage, elopement drills, elopement assessments and care plans, missing resident books and audits. * The Resident Elopement policy was revised on 7/29/17. Re-education regarding elopement and supervision was provided to facility staff starting from 7/29/17 to 8/03/17, including 73 nursing assistants, 40 licensed nurses and 65 departmental personnel. The education included identification of residents at risk for elopement, implementation of individualized interventions, revision of elopement policy, and utilization of the Missing Resident Books. Newly hired staff will be educated regarding elopement and supervision upon hire. On 7/29/17, the Resident Elopement Policy was revised and Code Gray elopement drills were conducted. * On 7/27/17, all 102 residents' elopement risk assessments were re-evaluated and on 7/30/17 all residents' cognitive status was validated along with mobility status and elopement risk. Of the 102 residents evaluated, 16 residents were physically able to leave the facility. These residents were educated regarding the leave of absence process. * On 7/29/17, all external doors were audited by maintenance and will continue to be audited daily. The front door will remain locked twenty four hours a day. Visitors entering or exiting the facility will be monitored by a staff member. On 7/29/17, education was provided to the receptionist and staff deemed appropriate to relieve the receptionist for breaks. * On 7/30/17, the residents at risk for exiting the facility or elopement was relayed to staff via the Missing Resident Books located at each nursing station, receptionist desk and therapy department. These residents had wander bracelets in place. * The wander bracelet placement and function checks was documented on the resident's treatment administration record. The unit manager will review the treatment administration record daily and report to QAPI. * All new admissions are to be reviewed daily in the morning clinical meeting including validation of accuracy of assessments, appropriate implementation of care plan interventions and verbal communication with staff regarding residents at risk for elopement or exit seeking behavior via daily updates of the Missing Resident Books by the unit managers. * All incidents and accidents are reviewed by the nurse management team in the morning meeting including documentation, evaluation, care plan updates and root cause analysis. The management team will validate effectiveness of education by conducting random audits during shifts. The staff will be presented with a series of questions of the education that was presented. The education will be revised or updated based on feedback from the audits. As of the exit date on 8/22/17, observations were made of the front door being locked at all times and the receptionist monitoring all who were entering or exiting the facility. A tour of the facility noted all doors were secure. It was noted that the facility was conducting Code Gray missing resident drills on each shift and validation of education was verified during interviews with the staff. Missing Resident Books were located at the nursing stations, reception and in therapy.

Based on observation, interview and record review, the facility failed to administer its resources effectively to ensure the supervision and safety of 1 of 4 sampled residents (#261). The administration failed to use their resources effectively and efficiently to ensure resident #261, at risk for elopement, was free from neglect, and failed to provide adequate supervision to ensure a safe and secure environment. This failure resulted in the elopement and potential serious injury/impairment/death of resident #261. Administration failed to identify the level of supervision needed for residents at risk for elopement, and were unable to provide adequate care that was identified as Past non-compliance at the Immediate Jeopardy level, identified as occurring on 2/11/17 and removed as of 8/03/17, before exit. Findings: Cross Reference: F223, F272, F323, F520. Resident #261, a [AGE] year old cognitively impaired, aphasic resident, identified at risk for elopement, left the faciity on [DATE] in his wheelchair. He traveled over a curb, [MEDICATION NAME] uneven grassy areas, crossed a 2 lane street onto a busy strip plaza parking lot located 0.3 miles from the facility near a busy 6 lane highway. The whereabouts of resident #261 were unknown by staff for almost 3 hours until he was spotted by an off duty staff member who was traveling on the busy 6 lane highway. The staff member telephoned the facility to inform them that she saw resident #261 in the parking lot of the convenience store near the busy highway. The resident was brought back to the facility by the weekend nursing supervisor. Resident #261 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was admitted from another long term care facility and was placed on the locked unit due to history of exit seeking behavior. He was relocated to an unlocked unit on 11/11/16. He had been deemed incapable of making medical decisions on 11/29/16. His primary mode of locomotion was via walker or wheelchair. A Risk for Elopement Assessment, dated 1/30/17, noted that the resident was at risk for elopement. The resident's comprehensive care plan, dated 10/28/16, noted that resident #261 was at risk for elopement with the goal that the resident will not be off facility property without supervision. There were no interventions listed on how or how often to supervise the resident to prevent elopement. The care plan was not updated post elopement to include any customary routines or approaches for individualized supervision to ensure a safe environment or any interventions to prevent elopement. The resident's Minimum Data Set (MDS-used to complete a comprehensive assessment of each resident) with assessment reference date (ARD) of 1/27/17 revealed that he had unclear speech and was sometimes understood, wandered 4-6 days per week, required 1 person extensive assist and had a brief interview for mental status (BIMS) score of 3/15, indicating severely impaired cognitive skills for decision making. On 8/21/17 at 2:07 PM, the two MDS coordinators and social service director revealed that social services was responsible for doing the BIMS test. They said that the social services assistant who is a certified nursing assistant conducted the BIMS assessment and that she had completed this incorrectly as the resident was not interviewable due to his unclear speech. They were not able to provide an answer when asked why the speech therapist who is trained in [MEDICAL CONDITION] was not utilized to assist with the BIMS interview. On 8/21/17 at 1:05 PM, the unit manager said that she was contacted by the administrator the first time the resident was observed sitting out on the front patio. She had suggested 1:1 staff observations of the resident. She said she was not aware that the resident had eloped to the convenience store until she read the 24 hour report on Monday morning, 2 days after the incident. She stated she was aware the administrator was dealing with the resident on 2/11/17 and Corporate was involved in deciding what to do. She could not explain why 1:1 or close supervision of the resident was not implemented rather than relying on the wander bracelet to keep the resident safe. On 8/21/17 at 5:15 PM, the administrator revealed that resident #261 had exited the facility on 2/11/17 at approximately 11 AM. He stated that he was informed by a nurse that resident #261 was out on the patio outside the front door. He could not explain how the receptionist on duty did not notice the resident exiting the front door. He said the resident was sitting in his wheelchair on the sidewalk under a tree and when asked what he was doing outside, he gestured to the tree and stated, shade. The administrator asked the resident to come inside and suggested a wander bracelet be placed on him. He stated the weekend supervisor was in agreement but when she tried to apply the wander bracelet, the resident refused, saying No. No. He stated that they were able to coax the resident into accepting the wander bracelet. When asked what the risk/danger was of the resident sitting outside under the tree, the administrator said it was not the resident's usual routine. The care plan was reviewed with the administrator and indicated that it was the resident's preference to be outside in the fresh air. The administrator could not provide an answer when asked why the resident could not be supervised while he was sitting outdoors. The administrator stated that he received a telephone call on 2/11/17 from the receptionist at 4:36 PM that the resident had left the building and was located near the convenience store. He said he was informed by the weekend supervisor that the resident had removed his wander bracelet but she could not determine how he did this. The administrator stated the resident was able to exit the front door when the receptionist went on her break, and the front door was left unattended. The administrator could not answer why the receptionist did not have a replacement for breaks. He was asked if the facility staff relied on wander bracelets rather than close supervision for keeping residents safe, but he could not provide an answer. The administrator could not explain why speech therapists, trained in [MEDICAL CONDITION] and experts with [MEDICAL CONDITION] residents, were not utilized to assess the resident when he was brought back from the elopement to question the resident why and how he left the facility. The administrator could not provide an incident report of the elopement incident as per their policy or provide documentation of a complete investigation other than a timeline of events. He stated that a decision was made to place the resident on the locked unit. When asked how the decision was made, the administrator stated that it was clinical judgement. When asked whose clinical judgement, he stated it was a decision made by the unit manager and staff development. When asked if an interdisciplinary team (IDT) meeting was held to assess if the resident should be placed on the locked unit, he stated that an IDT meeting was not held. He said he was in contact with the staff developer and the unit manager via telephone. He was not aware if the physician was contacted. A telephone interview with the weekend supervisor, licensed practical nurse (LPN) G on 8/22/17 at 1:30 PM revealed that she worked a double shift on the weekend of 2/11/17. She stated she was made aware by the administrator in the morning of 2/11/17 that resident #261 was outside on the front patio. She said she was instructed by the administrator to apply a wander bracelet on the resident. When asked if it was her clinical judgement to apply the wander bracelet, she stated that she was not familiar with the resident. She said she was asked by the administrator to apply the wander bracelet, if my boss asked me to do something, I do it. She said the second time, she received a call from rehab informing that resident #261 was observed near the convenience store. She stated that she was not aware that the resident was missing and could not explain how the resident had been out of the facility for almost 3 hours without staff knowledge of his whereabouts. She said that she went to bring the resident back. He was in his wheelchair on the sidewalk next to the busy 6 lane highway. Upon return to the facility, she noted that he did not have his wander bracelet that she had applied in the morning on his left wrist. She placed a new wander bracelet on the resident and placed him on the locked unit. When she was asked if she did any investigation as to what happened to the wander guard, she stated no. When she was questioned if an investigation was done as to why the resident left the facility, she stated no. When she was asked if any assessments were done prior to placing the resident on the locked unit, she stated no. She said she could have utilized staff to observe the resident closely or implement one to one (1:1) staff supervision with the resident but did not think of it. She said placement in the locked unit was to ensure the resident's safety but confirmed she had not discussed this measure with the resident's physician. She also stated that she did not utilize the speech therapist to assess the resident post elopement because she did not think of it. When she was asked how the administrator, who is not a clinician, made clinical decisions to apply wander bracelets and place a resident on the locked unit, she stated that he was in contact with corporate personnel. She could not explain why the policy was not followed for updating the resident's care plan and contacting the physician to address the elopement incident. She also confirmed that she had not received a physician order [REDACTED]. On 8/22/17 at 2:10 PM, the staff developer stated she was not involved in the decision to place resident #261 on the secured unit. She said the administrator had sent a group text on 2/11/17 informing her that the weekend supervisor had started education on resident elopement. The administrator's job description read, Responsible for the overall management of a facility. Plans, develops, directs, monitors and supports all operational, administrative, clinical, human resources, customer service and fiscal activities for the facility's programs and services. Ensures quality resident care is provided to meet or exceed company and regulatory standards. Makes sure the facility is a safe, clean and comfortable environment for residents in accordance with company guidelines. The facility's policy and procedure for Resident Elopement, last revised on 10/25/16, read, Upon return of the resident to the facility, the charge nurse will Contact the attending physician, report findings and conditions of the resident, and follow the physician's orders [REDACTED].Update the resident's care plan with interventions for elopement prevention Upon return of the resident to the facility, the administrator will follow the decision tree reporting guidelines. The facility failed to gain an overall awareness of the serious threat for residents posed by elopement. They failed to report the elopement incident of resident #261 to the physician and failed to utilize professional staff to assess and implement effective communication with the resident. The facility relied on the wander bracelet system and failed to utilize facility resources to assess and identify preventative measures to prevent elopement. Past non-compliance at the Immediate Jeopardy level was identified as occurring on 2/11/17 and removed as of 8/03/17, before exit. * The facility conducted an ad hoc Quality Assurance Performance Improvement (QAPI) meeting on 7/29/17 and held weekly QA meetings to address the elopement issue and initiated an action plan. The committee reviewed staff training and education, reception coverage, elopement assessments, care plans and audits. * The administrator will conduct daily meetings that include a morning meeting that will serve as the facility's risk identification meeting. This meeting includes a review of admissions, discharges, elopement risk, incidents and accidents. An afternoon meeting was also initiated to serve as the facility's risk resolution meeting where areas that were identified in the morning meeting are discussed and ensured to be resolved with appropriate interventions in place. * The Resident Elopement policy was revised and the Abuse and Neglect Prohibition policy was reviewed on 7/29/17. * Re-education regarding elopement and supervision was provided to facility staff starting from 7/29/17 to 8/03/17, including 73 nursing assistants, 40 licensed nurses and 65 departmental personnel. The education included identification of residents at risk for elopement, implementation of individualized interventions, revision of elopement policy, and utilization of the Missing Resident Books. * Newly hired staff will be educated regarding elopement and supervision upon hire. * On 7/27/17, all 102 residents' elopement risk assessments were re-evaluated, and on 7/30/17, all residents' cognitive status was validated along with mobility status and elopement risk. * On 7/29/17, all external doors were audited by maintenance and will continue to be audited daily. The front door will remain locked twenty four hours a day. Visitors entering or exiting the facility will be monitored by a staff member. * On 7/29/17, education was provided to the receptionist and staff deemed appropriate to relieve the receptionist for breaks. * All new admissions are to be reviewed daily in the morning clinical meeting including validation of accuracy of assessments, appropriate implementation of care plan interventions and verbal communication with staff regarding residents at risk for elopement or exit seeking behavior via daily updates of the Missing Resident Books by the unit managers. * All incidents and accidents are reviewed by the nurse management team in the morning meeting, including documentation, evaluation, care plan updates and root cause analysis. * The management team will validate effectiveness of education by conducting random audits during shifts. The staff will be presented with a series of questions of the education that was presented. The education will be revised or updated based on feedback from the audits. As of the exit date on 8/22/17, observations were made of the front door being locked at all times and the receptionist monitoring all who were entering or exiting the facility. A tour of the facility noted all doors were secure.

Based on observation, interview and record review, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) program for supervision of residents at risk for elopement. This resulted in the elopement of 1 of 4 residents and placed him at risk for potential serious injury/impairment/death (#261). The facility's QAA committee failed to identify quality deficiencies by not identifying the root cause analysis of the elopement incident and failed to evaluate and analyze the risk once an elopement and the potential for serious injury/impairment/death had occurred. The facility did not have a system in place to visualize all residents (head count) at the beginning, end and throughout each shift. There was no system in place for the front door to be secured at all times to ensure residents at risk did not exit the facility unsupervised. The facility did not have an effective assessment process to identify elopement risk or a system in place if resident did exit the facility without staff knowledge. These failures resulted in the resident's elopement and subsequent Past non-compliance at the Immediate Jeopardy level was identified as occurring on 2/11/17 and removed as of 8/03/17, before exit. Findings: Cross reference to F223, F272, F323, and F490. Resident #261 was admitted to the facility on [DATE] to a locked unit with [DIAGNOSES REDACTED]. His primary mode of locomotion was via wheelchair. He had been deemed incapable of making medical decisions on 11/29/16. Resident #261 was found outside sitting under the shade of a tree on 2/11/17 on a sunny day with a temperature of 80 degrees Fahrenheit. The resident's care plan identified that he preferred being outdoors and people watching. There was no indication that the resident was doing anything unsafe. The resident was brought inside and subjected to a wander bracelet against his wishes. At 1:38 PM, resident #261, identified at risk for elopement, left the facility via the unattended front door. His whereabouts were unknown to staff for approximately 3 hours until he was located 0.3 miles from the facility. The resident was observed by an off duty staff member who was driving by on the busy 6 lane highway. The staff member telephoned the facility to inform them that she saw resident #261 in the parking lot of a convenience store near the busy 6 lane highway. The facility's policy and procedure for Resident Elopement, last revised on 10/25/16, read, The facility strives to provide a safer environment and implements preventative measures to minimize elopement. On 8/21/17 at 12:30 PM, the admissions coordinator revealed that there was no admission assessment done to indicate the resident required a locked unit. She stated that the resident had been found outside at the previous facility, and that is why he was admitted to this facility's locked unit. On 11/11/16, the resident was transferred from the locked unit to the unlocked unit. On 8/21/17, the unit manager stated that the speech therapist recommended that the resident should be transferred out of the locked unit and it was approved by the physician. However, she could not provide a physician's orders [REDACTED]. She confirmed that there was no system in place to determine if residents required a locked unit or could be transferred off the locked unit. She also could not identify what type of supervision the resident required when he was off the locked unit, except to say, routinely but did not explain what that meant. On 8/21/17 at 5:15 PM, the administrator revealed that resident #261 had exited the facility on 2/11/17 at approximately 11 AM and was sitting outside on the patio under a tree. The administrator asked the resident to come inside, and a wander bracelet was placed on the resident's wrist. When the administrator was asked what the risk/danger was of the resident sitting outside under the tree, the administrator could not provide an answer other than it was not the resident's usual routine. The care plan was discussed with the administrator, and indicated that it was the resident's preference to be outside in the fresh air. The administrator could not provide an answer when asked why the resident could not be supervised while he was sitting outdoors. He stated that the resident was an elopement risk but could not explain how often residents at risk for elopement were to be observed. He also could not explain how the resident managed to get outside when the front door was manned by a receptionist. The administrator stated on 2/11/17 at approximately 4:36 PM, he received a telephone call from the receptionist that resident #261 had left the facility and was found near the convenience store. He was informed by the weekend supervisor that the resident had removed his wander bracelet and exited the facility. The administrator stated that the resident was able to exit the unattended front door when the receptionist went on her break. It was noted that there was no system in place for the front door to be secured when the receptionist was on her break. The resident was brought back to the facility, another wander bracelet was applied on the resident, and the resident was placed back on the locked unit. The administrator was asked if an investigation had been done to determine why and how the resident left the facility. He could not provide an investigation, only a timeline. He could not provide any assessments that determined that the resident should again be subjected to a wander bracelet and placed back on the locked unit. The administrator was asked how staff were unaware that resident #261 was missing for almost 3 hours, especially when there had been a change in the shifts. There was no system in place for staff to account for residents' whereabouts at the beginning, end, and during shifts. Although the elopement incident of resident #261 was serious and could have potentially resulted in serious bodily injury or death, the facility failed to recognize the root cause of the event. The facility focused on the event as an unauthorized leave and did not look at the elopement as systems problem. An interview with the administrator and corporate consultants on 8/22/17 at 6:05 PM revealed that although they identified the elopement incident of 2/11/17 as a serious event, they did not have an emergency QAA meeting following the incident. The incident was not discussed at the QAA meeting until 10 days later, on 2/21/17. The QAA committee failed to identify that a comprehensive assessment of the resident may have determined that the resident was exercising his preference to be outdoors (as per care plan) and not attempting to elope from the facility. A comprehensive assessment of the resident may have triggered a care plan with interventions to observe the resident closely when he was outdoors rather than slapping a wander bracelet on him. Instead the resident's care plan read that he was an elopement risk with measures to offer reassurance and support as needed and reorient to person, place and time as needed. There were no measures listed to supervise the resident or to exercise preference to be outdoors. Elopement is a serious issue and should be addressed at QAA meetings routinely. The facility had an at risk [AGE] year old resident who left the faciity on Saturday, 2/11/17. He walked with his wheelchair over curbs, uneven grassy areas, crossed a 2 lane street, walked across busy strip mall parking lot and was located 0.3 miles from the facility near a 6 lane busy highway. The QAA committee failed to fully investigate the elopement incident. They did not identify the root cause of the elopement and arrived at the conclusion that the the elopement was an unauthorized leave. Therefore, they focused on the incident rather than the elopement as a whole. They did not identify the failures in their systems for identifying and preventing elopement. There was no individualized care plan which outlined preventative measures, approaches, or activities to minimize elopement occurrences and to maintain a safe environment. The facility's response was based on reaction rather than prevention. Past non-compliance at the Immediate Jeopardy level was identified as occurring on 2/11/17 and removed as of 8/03/17, before exit. * The facility conducted an ad hoc Quality Assurance Performance Improvement (QAPI) meeting on 7/29/17 and held weekly QA meetings to address the elopement issue and initiated an action plan. The committee reviewed staff training and education, reception coverage, elopement drills, elopement assessments and care plans, missing resident books and audits. * The Resident Elopement policy was revised and the Abuse and Neglect Prohibition policy was reviewed on 7/29/17. * Re-education regarding elopement and supervision was provided to facility staff starting from 7/29/17 to 8/03/17, including 73 nursing assistants, 40 licensed nurses and 65 departmental personnel. The education included identification of residents at risk for elopement, implementation of individualized interventions, revision of elopement policy, and utilization of the Missing Resident Books. * Newly hired staff will be educated regarding elopement and supervision upon hire. * On 7/27/17, all 102 residents' elopement risk assessments were re-evaluated, and on 7/30/17 all residents' cognitive status were validated along with mobility status and elopement risk. Of the 102 residents evaluated, 16 residents were physically able to leave the facility. These residents were educated regarding the leave of absence process. * On 7/29/17, all external doors were audited by maintenance and will continue to be audited daily. The front door will remain locked twenty four hours a day. Visitors entering or exiting the facility will be monitored by a staff member. * On 7/29/17, Code Gray elopement drills were conducted. * On 7/29/17, education was provided to the receptionist and staff deemed appropriate to relieve the receptionist for breaks. * On 7/30/17, the residents at risk for exiting the facility or elopement was relayed to staff via the Missing Resident Books located at each nursing station, receptionist desk and therapy department. These residents had wander bracelets in place. * The wander bracelet placement and function checks is documented on the resident's treatment administration record. The unit manager will review the treatment administration record daily and report to QAPI. * All new admissions are to be reviewed daily in the morning clinical meeting including validation of accuracy of assessments, appropriate implementation of care plan interventions and verbal communication with staff regarding residents at risk for elopement or exit seeking behavior via daily updates of the Missing Resident Books by the unit managers. * All incidents and accidents are reviewed by the nurse management team in the morning meeting including documentation, evaluation, care plan updates and root cause analysis. * The management team will validate effectiveness of education by conducting random audits during shifts. The staff will be presented with a series of questions of the education that was presented. The education will be revised or updated based on feedback from the audits.

Based on record review and interview, the facility failed prevent the use of unnecessary restraints for 2 of 5 sampled residents with a [MEDICAL CONDITION] (#1,2). Findings: 1. Resident #1 was admitted to the facility on [DATE] with a history of ventilator dependent [MEDICAL CONDITIONS] (MRSA)pneumonia, [MEDICAL CONDITION] with isolation, [MEDICAL CONDITION] insufficiency, tracheotomy, [DEVICE] placement, [MEDICAL CONDITION] disease, diabetes, high blood pressure, stoke with right sided paralysis, and [MEDICAL CONDITION]. When she was admitted to the facility, she had the [MEDICAL CONDITION], but was no longer on the ventilator. She was admitted to room [ROOM NUMBER], a private room and required total assist of 1-2 staff members for activities of daily living. She was oriented to name only and could nod her head yes or no to questions. Review of progress notes dated 09/21/2010 at 2:49 p.m. revealed that the resident pulled out her tracheotomy tube and it was replaced by a respiratory therapist. A telephone order was obtained for a hand mitt to be placed on her left hand secondary to the resident pulling out her tracheotomy. The nurse who took the telephone order did not ascertain how long the restraint was to be applied, the frequency of release, and activities during restraint per facility policy. The order also did not specify whether or not the hand mitt was to be secured to the bed. The facility's Policy and Procedure Manual for Mitt Restraint #7 read that the mitt was to be released and the extremity exercised at least every two hours. There was no order to evaluate the appropriateness of the restraint. In an interview with the director of nursing on 11/15/11 around 10:42, she stated that the team makes the decision to include respiratory therapy, nursing and physical therapy, but physical therapy was never instructed to evaluate the restraint for this resident. Review of this resident's care plan dated 09/21/2011 revealed the focus of the care plan was the resident's removal of her tracheotomy cannula on 09/21/2011. The care plan interventions indicated that the hand mitt was to be applied as ordered to maintain an open airway. Review of the certified nursing assistants' (CNA) daily flow sheets did not indicate any use of a left hand mitt as a restraint or to release the restraint every 2 hours per policy and procedure. An interview was conducted with the CNA responsible for the resident on 09/24/2011 on the 11 p.m. - 7 a.m. shift. She stated that she checked the resident around 11 p.m. and noticed the mitt was in place. She again saw the resident at 2 a.m. and again the mitt was in place. At 3:40 a.m. when the Code Blue was called, she noted that the mitt was on the floor next to the bed. In an interview with a CNA working in the respiratory section of the facility on 11/15/11 around 5:45 a.m., she stated that she does not do anything with restraints or [MEDICAL CONDITION] patients. In an interview with the CNA working on the unit that cared for resident #1 on 11/15/11 around 5:30 a.m., she stated that she does not work with [MEDICAL CONDITION] residents and she has not worked with any restrained residents. In an interview with the director of nursing on 11/15/11 around 3:30, she stated that the facility did not have an assessment of the use of the restraint to ascertain the proper selection of restraint for the resident. The use of a restraint without evaluation of the appropriateness of the restraint for the resident and the resident's current condition makes the use of this restraint unnecessary. The restraint was not appropriate or effective in preventing the resident from removing her [MEDICAL CONDITION] device which resulted in her death. 2. Record review for resident #2 revealed a history [MEDICAL CONDITION] with pseudomonas pneumonia, acute respiratory insufficiency, chronic respiratory insufficiency, status [REDACTED]. On 9/28/11 the physician order [REDACTED]. On 9/29/11 an order read " hand mitt to right hand; to prevent patient self decannulation. Removed for activities, ADL's, therapy, assess for placement, skin integrity, and circulation, removed as needed every 2 hours. " The physician order [REDACTED]." The hand mitt was not discontinued at that time. Review of the physician order [REDACTED]. In an interview with the director of nursing on 11/15/11 around 3:30, she stated that the facility did not have an assessment of the use of the restraint to ascertain the proper selection of restraint for the resident. Review of treatment sheet for this resident revealed that the resident had hand mitt in use until the order to discontinue it on 10/21/11. The resident was decannulated on 10/15/11 and the restraint was in use for 6 days when it was not necessary to prevent self decannulation. There was no documentation of an assessment regarding the appropriateness of the restraint.

Based on record review and interview, the facility failed to provide services to meet the professional standards of quality as stated in the nurse practice act: Florida Board of Nursing, Nurse Practice Act, 464.003 (3)(a)(1)(2), states that the practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (1) the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care... This failure was reflected in 2 of 5 residents reviewed. (#1 & 2) Findings: 1. Resident #1 was admitted to the facility on [DATE] with a history of ventilator dependent [MEDICAL CONDITIONS] (MRSA)pneumonia, [MEDICAL CONDITION] with isolation, [MEDICAL CONDITION] insufficiency, tracheotomy, [DEVICE] placement, [MEDICAL CONDITION] disease, diabetes, high blood pressure, stoke with right sided paralysis, and [MEDICAL CONDITION]. When she was admitted to the facility, she had the [MEDICAL CONDITION] but was no longer on the ventilator. She was admitted to room [ROOM NUMBER], a private room and required total assist of 1-2 staff members for activities of daily living. She was oriented to name only and could nod her head yes or no to questions. Review of progress notes dated 09/21/2010 at 2:49 PM revealed that the resident pulled out her tracheotomy tube and it was replaced by a respiratory therapist. A telephone order was obtained for a hand mitt to be placed on her left hand secondary to the resident pulling out her tracheotomy. The nurse who took the telephone order did not ascertain how long the restraint was to be applied, the frequency of release and activities during restraint per facility policy. The order also did not specify whether or not the hand mitt was to be secured to the bed. The facility's Policy and Procedure Manual for Mitt Restraint #7 read that the mitt was to be released and the extremity exercised at least every two hours. There was no order to evaluate the appropriateness of the restraint. In an interview with the director of nursing on 11/15/11 around 10:42, she stated that the team makes the decision to include respiratory therapy, nursing and physical therapy. She also stated she had searched the records and that there was no evaluation for appropriateness of the restraint. Review of this resident's care plan dated 09/21/2011 revealed the focus of the care plan was the resident's removal of her tracheotomy cannula on 09/21/2011. The care plan under interventions stated that the hand mitt was to be applied as ordered to maintain an open airway. There were no interventions for time of release, exercise of the extremity, or timing for checking the restraint. Review of the certified nursing assistants' (CNA) daily flow sheets did not indicate any use of a left hand mitt as a restraint or to release the restraint every 2 hours per policy and procedure. An interview was conducted with the CNA responsible for the resident on 09/24/2011 on the 11 PM - 7 AM Shift. She stated that she checked the resident around 11 p.m. and noticed the mitt was in place. She again saw the resident at 2 a.m. and again the mitt was in place. At 3:40 a.m. when the Code Blue was called, she noted that the mitt was on the floor next to the bed. In an interview with a CNA working in the respiratory section of the facility on 11/15/11 around 5:45 a.m., she stated that she does not do anything with restraints or [MEDICAL CONDITION] patients. In an interview with the CNA working on the unit that cared for resident #1 on 11/15/11 around 5:30 a.m., she stated that she does not work with [MEDICAL CONDITION] residents and she has not worked with any restrained residents. In an interview with the director of nursing on 11/15/11 around 3:30 p.m., she stated that the facility did not have an assessment of the use of the restraint to ascertain the proper selection of restraint for the resident. The use of a restraint without evaluation of the appropriateness of the restraint for the resident and the resident's current condition makes the use of this restraint unnecessary. The restraint was not appropriate or effective in preventing the resident from removing her [MEDICAL CONDITION] device which resulted in her death. 2. Record review for resident #2 revealed a history [MEDICAL CONDITION] with pseudomonas pneumonia, acute respiratory insufficiency, chronic respiratory insufficiency, status [REDACTED]. On 9/28/11 the physician order [REDACTED]. On 9/29/11 there was an order that read " hand mitt to right hand; to prevent patient self decannulation. Removed for activities, ADL's, therapy, assess for placement, skin integrity, and circulation, removed as needed every 2 hours. " The physician order [REDACTED]." Review of the physician order [REDACTED]. In an interview with the director of nursing on 11/15/11 around 3:30, she stated that the facility did not have an assessment of the use of the restraint to ascertain the proper selection of restraint for the resident. Review of treatment sheet for this resident revealed that the resident had a hand mitt in use until the order to discontinue it on 10/21/11. The resident was decannulated on 10/15/11 and the restraint was in use for 6 days when it was not necessary to prevent self decannulation. There is no documentation of an assessment regarding the appropriateness of the restraint.