Parkside Homes

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent a significant medication error involving a hospice resident diagnosed with dementia and agitation. The resident's care plan required the administration of medications as ordered, with monitoring for side effects and effectiveness. However, a Licensed Nurse administered five times the prescribed dose of topical Ativan, a medication used to treat anxiety, due to misreading the syringe. The error was not discovered until two days later when another nurse identified the mistake. The facility's policy on medication administration mandates that the individual administering medication must verify the right medication, dosage, time, and method of administration by checking the label three times. Despite this policy, the Licensed Nurse did not adhere to these procedures, resulting in the medication error. The incident was reported to the physician, but no new orders were received, and the facility's documentation lacked details on the resident's response to the overdose.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide an environment free from accident hazards for several residents, leading to multiple deficiencies. One resident, with a history of falls and severe cognitive impairment, was found on the floor attempting to put on socks, indicating a lack of effective fall prevention interventions in their care plan. Despite being at high risk for falls, the resident's care plan lacked safety interventions until after a fall occurred. Additionally, the facility did not conduct a fall investigation following the incident. Another resident, who had a history of falls and was at high risk according to the Morse Fall Scale, fell and sustained deep lacerations requiring emergency treatment. The facility failed to include fall prevention interventions in the resident's care plan, and there was inadequate documentation of neurological assessments and follow-up care. The resident's care plan was not updated promptly to address the fall risk, and the facility did not provide a thorough investigation into the fall. The facility also failed to ensure adequate supervision for residents with high fall risks. One resident was left unattended in a bathroom while attached to a mechanical lift, and another resident was left in a wheelchair in their room, despite being at high risk for falls. These actions demonstrate a lack of adherence to the facility's policies on fall prevention and care planning, resulting in an environment that was not free from accident hazards.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that meals were served at safe and appetizing temperatures, as evidenced by multiple observations and resident complaints. Two residents, including the President of the Resident Council, reported that food was often served cold when it should have been hot. During meal service, dietary staff were observed serving food at temperatures below the acceptable range. For instance, pureed sausage gravy and toast were served at 100 degrees Fahrenheit, which was acknowledged as unacceptable by the Dietary Manager. Additionally, food items such as chicken and hamburger patties were not consistently temped before being placed in delivery carts, leading to further temperature discrepancies upon arrival at the dining areas. The report highlights several instances where dietary staff failed to maintain proper food handling procedures. Food was left uncovered, and thermometers were not sanitized between uses, leading to potential cross-contamination. The facility's policy required food to be held at temperatures between 41 degrees F and 135 degrees F, yet several food items were served outside this range. The Dietary Manager and Administrative Staff confirmed the concerns regarding food temperatures, acknowledging the multiple complaints from residents about the palatability of food due to temperature issues. This deficiency placed residents at risk for impaired nutrition, as stated in the report.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store, prepare, and serve food in a sanitary manner, which could potentially lead to food-borne illnesses among residents. During observations, numerous food items in both the small dining room kitchen and the main kitchen were found to be improperly stored. These items included opened and unsealed bags of various foods such as French toast, ice cream, muffins, bagels, and more, all lacking open dates or labels. Additionally, some food items, like a bag of salami, showed signs of spoilage with dried brown and green edges. The Dietary Manager confirmed these concerns, acknowledging the lack of proper labeling and sealing as unacceptable. Further issues were observed with staff hygiene practices. Dietary Staff G was seen handling food and interacting with residents without performing proper hand hygiene, even after touching his face and handling soiled dishes. This was confirmed by the Dietary Manager as a concern. Additionally, the kitchen equipment was found to be in poor condition, with ovens containing burned food debris and cutting boards and fry pans showing significant wear and damage. The facility's policies on hand hygiene and food preparation were not adhered to, as staff failed to follow proper procedures for hand washing and food storage.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during the survey. A resident's nebulizer was not properly cleaned and stored, with the nebulizer cup and mouthpiece left intact on the machine and not disassembled or rinsed after use. Additionally, oxygen concentrators in residents' rooms were found with undated tubing and humidifier bottles containing cloudy liquid, indicating improper maintenance and storage of respiratory equipment. Dietary staff were observed lacking proper hand hygiene during meal service, touching their face and handling soiled dishes without washing hands before serving food to residents. This was confirmed as a concern by both the Dietary Manager and the Administrative Nurse. Furthermore, a resident with open wounds and drainage was assisted to the dining area without appropriate enhanced barrier precautions, as there was no signage or PPE bag indicating the need for such precautions. The facility also demonstrated improper sterile technique during a PICC line dressing change, where the sterile field was contaminated by touching the outside of the package with sterile gloves. Additionally, staff failed to perform hand hygiene after removing soiled gloves during catheter care. These actions and inactions contributed to the facility's failure to implement an effective infection prevention and control program, potentially leading to the spread of infections among residents.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adherence to antibiotic stewardship principles, leading to inappropriate antibiotic use among residents. The Infection Preventionist, Administrative Nurse C, reported difficulties in tracking antibiotic use due to incomplete infection screening evaluations and lack of adherence to McGeer's Criteria by the nursing staff. This resulted in antibiotics being administered and completed before a proper evaluation could be conducted. Additionally, the Antibiotic Assessment Tool in the Electronic Health Record (EHR) was not utilized during the antibiotic treatment period, further complicating the monitoring process. Both Administrative Nurse C and Administrative Nurse B acknowledged the presence of unnecessary prophylactic antibiotics being prescribed without consultation with the prescribing provider or the medical director. The facility's Infection Control Policy, which includes guidelines for antibiotic stewardship, was not followed, as there was no collaboration with the Medical Director, Pharmacist, or Director of Nursing to monitor antibiotic use. This lack of communication and adherence to policy contributed to the failure in providing ongoing antibiotic stewardship, increasing the risk of antibiotic resistance and the spread of multidrug-resistant organisms within the facility.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to address and resolve recurring issues reported by the Resident Council, specifically concerning food temperatures. Over the course of a year, from September 2023 to September 2024, the Resident Council minutes documented repeated concerns about food being served at inappropriate temperatures. Specific instances included corn dogs being served icy inside, and hamburgers and tater tots being served cold. Despite these recurring complaints, the minutes lacked documentation of actions taken or outcomes achieved to address these issues. Interviews and observations revealed further deficiencies in the facility's grievance handling process. The Social Services Designee (SSD) was unable to produce a grievance log reflecting the residents' multiple concerns about food temperatures. Additionally, the SSD mentioned that the kitchen staff had access to a plate warmer that was intermittently operational, but was unsure of its current status. The facility's policy on the right to voice grievances stated that residents had the right to expect prompt efforts by the facility staff to resolve grievances, yet this was not adhered to, placing residents at risk for decreased psychosocial well-being and impaired quality of life.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that one of the four medication carts observed was locked while unattended, which had the potential to affect 14 residents on the main campus. During an observation, an unlocked medication cart was found unattended in the main common area, with all medication drawers easily accessible. No staff was present for approximately two minutes until a Certified Medication Aide (CMA) returned from obtaining ice for the cart. The CMA acknowledged that the cart should have been locked when unattended and not in her line of sight. Administrative Staff confirmed the concern, noting that the cart should have been secured when not attended by staff. The facility's policy on Medication Labeling and Storage did not include documentation requiring medication carts to be locked or secured.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's advanced directives were thoroughly completed, specifically for a resident with a Do Not Resuscitate (DNR) order. The resident, identified as R16, had a DNR order that was only signed by a physician, lacking the necessary additional signatures to validate the document according to the facility's policy and state law. This oversight was confirmed by the Social Service Designee, who acknowledged that the DNR uploaded in the Electronic Health Record (EHR) was incorrect. R16 was a resident with diagnoses of dementia and depression, exhibiting severely impaired cognition and requiring total assistance with activities of daily living. The resident's care plan and physician orders indicated a DNR status, which was visually represented by a red dot on the resident's name tag outside their room. Despite these indicators, the facility's failure to ensure a fully completed advanced directive had the potential to lead to uncommunicated needs, particularly concerning end-of-life care.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the responsible party of a resident when there was a change in the resident's medication order. The resident, who had diagnoses of dementia and encephalopathy, was receiving Seroquel, an antipsychotic medication, for delusional behaviors. On September 6, 2024, the physician ordered a decrease in the Seroquel dosage to once daily at bedtime for a gradual dose reduction. However, the facility's progress notes did not show evidence that the resident's responsible party was informed of this medication change. Interviews with the resident's family member and facility staff confirmed the lack of notification. The family member reported that the last notification received from the facility was regarding a fall in August 2024. Licensed Nurse K and Social Service Designee E stated that it was the charge nurse's responsibility to notify the responsible party of any medication change and document it in the electronic health record. Administrative Nurse C also confirmed this procedure. Despite these protocols, the facility did not have a policy regarding notification of change, leading to the deficiency.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide written notification of the bed hold policy to three residents or their representatives during hospital transfers. This deficiency was identified for residents R2, R10, and R31, who were transferred to hospitals without receiving the required written notice about the facility's bed hold policy. The absence of this documentation placed these residents at risk of not being able to return to their original rooms upon discharge from the hospital. For Resident R2, the electronic health record indicated diagnoses including cellulitis, pseudomonas, urinary tract infection, and dementia. Despite having intact cognition, as evidenced by a BIMS score of 15, there was no documentation in the care plan or progress notes regarding the notification of the bed hold policy during hospital transfers on two occasions. Interviews with facility staff revealed that the licensed nurse on duty was responsible for completing bed hold documentation, but this was not done, and no written notice was provided to the resident or their representative. Resident R31, who had severe cognitive impairment and required substantial assistance with activities of daily living, was also transferred to a hospital without receiving a written bed hold notice. Similarly, Resident R10, with moderately impaired cognition and multiple diagnoses including dementia and West Nile virus, was transferred without the required documentation. Facility staff confirmed that the bed hold policy was communicated verbally, but no written documentation was provided, contrary to the facility's policy requiring written notice at the time of transfer.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The report highlights a deficiency related to the monitoring and reporting of a resident's vital signs and health status. A resident with a history of hypertension had a blood pressure reading of 163/112, which exceeded the parameters set for reporting to the primary care physician. However, there is no documentation indicating that this elevated blood pressure was reported to the physician or hospice, as expected by the facility's protocol. Additionally, there was an incident where the resident's oxygen saturation level dropped to 73, yet it was not reported, which is considered unacceptable by the facility's standards. The resident experienced several health episodes, including involuntary movements, rapid respirations, and a significant headache, which were not adequately addressed. The resident's medications were held due to her altered state, but there is no indication that the underlying causes of her symptoms were thoroughly investigated or that appropriate interventions were implemented. Furthermore, the resident's skin assessment revealed a new bruise on her lower arm, which was not documented or analyzed for root cause, as required by the facility's procedures. Interviews with staff members revealed inconsistencies in the care provided, particularly in the monitoring and documentation of the resident's condition. The LPN acknowledged the need to manually recheck abnormal vital signs and notify the doctor, but there was a lack of follow-through in documenting these actions. The facility's policy on checking and changing residents was also noted to have been altered, potentially impacting the resident's care. Overall, the report indicates a failure in communication and documentation, leading to inadequate monitoring and response to the resident's health needs.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately assess and document the care needs of several residents, leading to deficiencies in their care plans and Minimum Data Set (MDS) assessments. Resident 24, who had a history of falls and was at high risk for future falls, experienced a fall on 06/21/24 that was not properly investigated or documented in the care plan. The fall investigation report was delayed, lacked immediate interventions, and was missing a staff signature. This oversight resulted in uncommunicated care needs and placed the resident at risk for ongoing falls. Resident 35's MDS was inaccurately completed, failing to document insulin injections and falls with minor injuries. Despite having a history of falls and receiving insulin injections, these were not captured in the MDS, which could lead to uncommunicated care needs. The facility's policy required accurate MDS assessments, but the failure to adhere to this policy resulted in a lack of proper documentation and communication regarding the resident's care needs. Resident 31's MDS also contained inaccuracies, as it did not reflect the use of a Foley catheter and oxygen, which were part of the resident's care. The resident's care plan and physician orders lacked documentation of these interventions, despite progress notes indicating their use. This discrepancy between the resident's actual care needs and the documented MDS assessments could lead to uncommunicated care needs and potential risks to the resident's health.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a person-centered baseline care plan for a resident, identified as R238, within 48 hours of admission, as required by their policy. The resident had a complex medical history, including conditions such as extradural and subdural abscess, MRSA infection, sepsis, anxiety, severe protein-calorie malnutrition, acute kidney failure, and management of a vascular device. Despite these significant health issues, the baseline care plan did not include necessary interventions to prevent falls, even though the resident had a documented history of falls prior to admission. The resident was assessed with a high risk for falls, as indicated by a Morse Fall Scale score of 95. However, the baseline care plan lacked specific interventions to address this risk. The resident experienced a fall on 09/26/24, resulting in serious injuries, including multiple lacerations to the head and face, which required medical attention and stitches. The incident note from the fall indicated that the resident was found on the floor with blood present, and the resident was not able to recall how the fall occurred. Interviews with facility staff revealed that the baseline care plan was supposed to be completed by a nurse and reviewed with the resident and/or their family. However, the care plan did not adequately address the resident's fall risk or provide enhanced barrier precautions for the resident's surgical wound. The facility's failure to implement a comprehensive baseline care plan contributed to an environment that was not free from accident hazards, as evidenced by the resident's fall and subsequent injuries.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive care plan with interventions to address enhanced barrier precautions for a resident's wounds, which compromised infection control measures and placed other residents at risk. The resident, identified as R12, had a history of hypertension, chronic kidney disease, venous thrombosis, and vascular implants. She was assessed to have venous stasis ulcers on both lower legs, which required nonsurgical dressing. Despite the presence of these wounds, the care plan lacked specific interventions related to enhanced barrier precautions, and the resident frequently refused to wear prescribed Tubigrip bandages due to pain. Observations and interviews revealed that the facility did not consistently implement enhanced barrier precautions for R12. Staff members, including a licensed nurse and certified nurse aides, were observed not using appropriate personal protective equipment (PPE) during care activities. The facility's policy required enhanced barrier precautions for wounds that could serve as a reservoir for multidrug-resistant organisms, yet there was no consistent signage or PPE setup to indicate the need for such precautions. Interviews with staff indicated confusion and inconsistency in the application of these precautions, with some staff unaware of the need for enhanced barrier precautions for R12. The resident's wounds were documented to have increased drainage, redness, and inflammation, with observations noting the absence of dressings or coverings on her legs. Despite the presence of drainage and the resident's mobility in common areas, the facility did not ensure that enhanced barrier precautions were consistently applied. This oversight in infection control measures, coupled with the resident's refusal to adhere to treatment orders, highlighted a significant deficiency in the facility's care planning and infection control practices.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to review and revise the comprehensive care plan for two residents, R24 and R31, related to falls and accident hazards. For Resident 24, the care plan did not include an intervention related to a fall that occurred on 06/21/24. The resident was found on the floor in the pantry area after attempting to get a soda, and although the fall was documented, there was no immediate intervention to prevent further falls. Additionally, the fall investigation report was not completed in a timely manner and lacked a signature from the staff member or licensed nurse who completed it. Resident 31's care plan also lacked timely updates following a fall. The resident, who had severely impaired cognition and required maximal assistance with activities of daily living, experienced a fall on 02/17/24 while attempting to put on socks. The care plan was not updated with fall prevention interventions until ten days after the incident. The facility failed to provide a fall investigation report upon inquiry, and observations revealed that the resident's call pendant was not always within reach, which could have contributed to the risk of falls. The facility's policy required care plans to be updated with interventions related to changes such as falls, but this was not adhered to in the cases of R24 and R31. The lack of timely updates to the care plans placed both residents at risk for uncommunicated care needs and further falls, potentially impacting their physical and psychosocial well-being.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately assess and address skin issues for a resident, identified as R12, who had a history of hypertension, chronic kidney disease, and venous thrombosis, among other conditions. Despite having a potential for skin impairment documented in the resident's care assessments, the facility did not implement or document any interventions related to the resident's skin or wounds in the comprehensive care plan. The resident had venous ulcers on her lower extremities, but the care plan lacked specific interventions to manage these conditions. The resident's medical records revealed multiple refusals of prescribed treatments, such as Tubigrip, which were intended to manage her skin condition. Despite these refusals, there was no documented follow-up or alternative interventions noted in the records. Observations showed that the resident's legs were swollen, red, and had open areas with drainage, yet there were instances where no dressings or coverings were applied. The facility's documentation was inconsistent, with missing assessments and a lack of follow-up on identified skin issues. Interviews with facility staff indicated a lack of adherence to the facility's policy on skin integrity, which required documentation and follow-up on skin deviations. The staff failed to consistently document skin assessments and did not perform regular evaluations as expected. This lack of action and documentation placed the resident at an increased risk for further medical complications, as the facility did not adequately address the resident's skin issues in a timely and effective manner.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide safe and appropriate respiratory care for several residents, leading to potential respiratory complications. Resident 13, who had a diagnosis of asthma, was observed with a nebulizer that was not properly cleaned or stored. The nebulizer was left intact and draped over the arm of a recliner, contrary to the facility's policy which required disassembly, rinsing with tap water, and air drying on a paper towel after each use. The care plan for Resident 13 lacked documentation related to the care and use of the nebulizer, and the staff did not follow the cleaning schedule outlined in the physician's orders. Resident 31, who had severe cognitive impairment and required substantial assistance with activities of daily living, had an oxygen concentrator in her room with tubing that was not dated and a humidifier bottle filled with cloudy liquid. The nasal cannula was improperly stored, wrapped around the concentrator and exposed to the environment. The facility's policy did not include proper labeling and storage instructions for oxygen equipment, and there was no physician order reflecting Resident 31's oxygen use, despite hospital admission orders indicating the need for supplemental oxygen. Resident 3, who had multiple diagnoses including congestive heart failure and obstructive sleep apnea, was observed with oxygen tubing that lacked a date and was improperly stored, with nasal prongs resting on the floor. The facility's policy required oxygen tubing to be changed and dated regularly, but this was not adhered to. The improper storage of oxygen equipment for Resident 3 posed a risk of contamination and potential respiratory complications.

Penalty

Inspection fine: $43,5448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide the necessary declination forms for pneumococcal and influenza vaccines for several residents, as required by their policies. Specifically, the electronic health records for four residents lacked documentation of the pneumococcal vaccine declination form, and one resident's record lacked documentation of the influenza vaccine declination form. The facility's policy mandates that residents or their legal representatives receive education about the benefits and potential side effects of these vaccines, and that the medical record should document whether the vaccine was administered or declined due to medical contradictions or refusal. During interviews, it was revealed that the administrative nurses could not locate the signed consent or declination forms for the pneumococcal vaccine for the affected residents. Additionally, one resident who requested the pneumococcal vaccine had not received it due to ongoing therapy and concerns about the vaccine's side effects interfering with therapy. The administrative nurse also confirmed that a verbal declination for the influenza vaccine was considered acceptable by the pharmacy, although this was not documented in the resident's record.

Penalty

Inspection fine: $13,397

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision and a safe environment for a cognitively impaired resident, leading to an elopement incident. The resident, diagnosed with dementia and amnesia, exhibited severe cognitive impairment and was independently mobile. On the day of the incident, the resident attempted to leave the facility multiple times, expressing agitation and a desire to leave. Despite these clear exit-seeking behaviors, the staff did not apply a Wanderguard bracelet or take sufficient measures to prevent the resident from eloping. The resident first attempted to exit the front door and then moved to the gated courtyard, followed by staff. After spending approximately 45 to 60 minutes outside with staff, the resident was brought back inside the main building. Later in the day, the resident was let out of the front entrance by a visitor and was found 11 minutes later in the parking lot by a CNA. The staff was unaware of the resident's elopement until the CNA saw the resident outside. Interviews with staff revealed that the resident had been displaying exit-seeking behaviors throughout the day, including packing belongings and expressing a desire to leave. Despite these behaviors, the staff did not implement the facility's elopement policy, which included placing a Wanderguard bracelet on the resident. The facility's failure to provide adequate supervision and implement necessary safety measures placed the resident in immediate jeopardy.

Removal Plan

• R1 placed on one-to-one observation following the elopement until she went to bed and LN G educated the visitor about not letting others out without speaking to the nurse first.
• An elopement assessment completed, care plan updated, and a Wanderguard bracelet placed on R1.
• An elopement action plan completed.
• A Root Cause completed for R1 which determined she was on isolation for COVID prior to the day of the incident.
• The facility medical director, who was also R1's primary care physician, contacted and reviewed the action plan, root cause, policy changes, education plans and advised to place a sign on the exit doors to keep visitors from allowing exit advising them to see the nurse for assistance before opening the door.
• The facility contacted the resident representative to inform about care plan updates with interventions to new elopement risks.
• A full audit on elopement assessments completed and updated pictures placed at all nurse's stations for all residents with identified elopement risks to educate all staff and all agency staff of residents at risk.
• All staff provided immediate education on elopement policy update.
• Signs placed on all exit doors: Elopement Risk - do not open the door for someone you do not know or allow someone to follow you out the door unless they are with your party. For assistance please call [specified number] and a nurse will come to assist you. Thank you for keeping our resident's safe.
• Elopement Drill completed to test staff competency of elopement policy and procedure with an incident after action plan completed. A new intervention to add sign to the gate exits: Make sure gate is closed behind you, if you find the gate door open notify a nurse immediately.
• All staff educated on non-pharmacological approaches to support individuals living with dementia, maintain isolation precautions, interventions to help prevent behaviors and exit seeking, Abuse, Neglect, and Exploitation policy, and updated policy for resident isolation procedures.