cms_GA: 2025
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2025 | ORCHARD HEALTH AND REHABILITATION | 115522 | 1321 PULASKI SCHOOL ROAD | PULASKI | GA | 30451 | 2017-10-08 | 323 | J | 1 | 0 | UU0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to provide a secure environment for one resident (R) #1 of six residents sampled with a known history of elopement and elopement attempts. After a successful elopement from the facility on [DATE], the facility failed to address the resident's risks after the elopement, failed to assess for and evaluate those risks, and failed to implement interventions to reduce those risks. R#1 was able to successfully elope a second time and was found, deceased , four days after the elopement. The sample size was 6 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The immediate jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the resident eloped on [DATE], that the facility failed to update the resident's care plan and failed to put new care plan interventions in place to prevent the resident from eloping from the facility again. On [DATE], R#1 eloped from the facility between the hours of 10:30 a.m. and 1:30 p.m. The resident was last seen in the morning exercise class scheduled on [DATE] from 10:00 a.m. to 10:30 a.m. The facility realized that the resident was missing at approximately 1:10 p.m. when the kitchen staff observed that the resident's lunch tray was still on the serving cart. The resident's family, physician, and police were notified. Foot patrols were begun by the Sheriff's office and nursing home volunteers. Additional searches were conducted until [DATE], at approximately 1:30 p.m. when R#1 was found approximately a quarter of a mile from the facility, deceased . The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 278 SS=J 483.20(g)-(j) Assessment Accuracy/Coordination/Certified, F280 S/S: J 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) Right to participate in planning care - Revise care plan, F 323 SS=J 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devises F 490 SS=J 483.70 Effective Administration/Resident well-being. Additionally, Substandard Quality of Care was identified with the requirements at F 323 SS=J 483.25(d) (1) (2) (n) (1)-(3) Free of Accident Hazards/Supervision/Devices. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessments related to elopement, updating and revising care plans, systematic review of residents and the physical environment for elopement risks. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including assessments and care plans were current and accurate. The IJ was removed on [DATE]. Findings include: Clinical record review for R#1 revealed the resident had the following diagnoses, including but not limited to: unspecified psychosis, generalized anxiety disorder, adjustment disorder, unspecified dementia, schizophrenia, and dementia with behavior disturbance. Review of R#1's Minimum Data Set (MDS) annual review dated [DATE] revealed under Section C - Cognition, that resident was severely cognitively impaired. Under Section [NAME] - Behaviors, R#1 is not coded for wandering behavior, but his previous MDS assessments from [DATE] through [DATE] were coded for wandering. Resident also had delusions, exhibited verbal behaviors ,[DATE] days of the review period and exhibited other behaviors ,[DATE] days of the review period. Under section G- Functional Status, the resident required supervision for most activities of daily living, but needed extensive assistance to dress and maintain personal hygiene. Review of the 'Interdisciplinary Progress Notes' dated [DATE] at 10:15 p.m. and recorded by nursing staff revealed an assessment for a fall that occurred on [DATE] with an additional notation that read: also, at 4:35 p.m. staff member alerted nurse that Mr. (R#1) had left the premises. Nurse writer and 3 other staff members went outside to search for him. Resident had waked (sic) about 1 mile down HWY 46 and was returned to facility by staff member. There were no injuries noted to body. Appeared to be in no distress. Resident showed nurse writer how he had gotten out. Apparently, while the heating and air service men were working on the unit they left the door open and Mr. (R#1) walked outside. Resident stated, I'm sorry, I was just trying to get home. Review of R#1's current 'Plan of Care' for wandering/elopement revealed it originated on [DATE] and had not been updated or revised related to the elopement on [DATE]. Interview with the Administrator on [DATE] at 1:40 p.m. revealed that R#1 eloped from the facility on [DATE] sometime after 10:45 a.m. Staff discovered the resident was missing at approximately 1:30 p.m., searched the facility, and notified the Administrator at 1:45 p.m. The Administrator alerted the local police and a search for the resident was initiated. Continuing interview with the Administrator revealed that the resident had successfully eloped previously on [DATE]. Exterior tour and interview on [DATE] at 11:35 a.m. with the Engineering and Safety Manager QQ reveals that all gates are padlocked with the exception of the front gate which is secured with a maglock. The fencing is approximately 4 1/2 feet tall, there are two types of fence, but no large gaps in between them. Engineering and Safety Manager QQ confirms that this is the same fencing that was in place in (YEAR). Engineering and Safety Manager QQ states that he never observed R#1 hanging around the secured doors, trying to get out of the building or trying to leave the secured exterior, but that the resident was known to observe the door codes. When asked how the facility addressed this, the Engineering and Safety Manager QQ stated that the door codes were changed when it was reported to him. Interview on [DATE] at 3:05 p.m. with Activities Director KK who confirmed that resident was with her for activities on [DATE]. Activities finished at 10:30 a.m. but that R#1 stayed with her to visit, until approximately 10:45 a.m. Activities Director KK revealed that she believed the resident exited through the secure door of the hall next to the dining room. That is where R#1 put his wheelchair prior to activities. Activities Director KK confirmed that R#1 did not need the wheelchair to ambulate, but was encouraged to use it because of his unsteady gait. Activities Director KK revealed that R#1 would have been able to see the contracted staff out the dining room window during that mornings activities, and also stated that when resident's family visited, he wanted to go home with them. Once they left, he was easily re-directed due to his short-term memory loss. Activities Director KK confirmed that he was pretty happy most of the time, liked to watch television, enjoyed smoke breaks and was involved with everything. He had problems with some residents when he wandered into their rooms. He was curious and impulsive and said that he wanted to learn to drive and get a car. He was aware that the doors locked and would try to catch them before they closed. Activities Director KK states that she never reported this because it was not new behavior for this resident. Interview with the Administrator and the Regional Vice-President on [DATE] at 10:45 a.m. revealed that R#1's [DATE] elopement was discussed during the scheduled Quality Assurance and Performance Improvement (QAPI) meeting on [DATE] at 12:00 p.m. No changes were recommended to R#1's plan of care, at that time. The facility implemented monthly checks of the secured doors for functionality and security as an intervention and the door codes were changed as a precaution. Changes to the secured code for the doors occur 'as needed'. Monthly monitoring logs continue to be maintained of the secured door checks, but no monitoring of the efficacy of this intervention was recorded. Interview on [DATE] at 11:10 a.m. with the DON revealed that she confirmed that the resident had previously eloped in (YEAR) under very similar circumstances to the residents elopement on [DATE]. In (YEAR) the contractors were there to make repairs on the air conditioning units and the resident exited the building through the open gate. The DON further revealed that R#1 paid attention to the door codes and that he was probably able to let himself out. She further states that the facility made a policy change requiring that the secured doors be checked monthly after R#1's elopement in (YEAR). Further interview revealed that there was no follow-up or tracking tool used to measure the effectiveness of this intervention and that there was not a re-assessment completed for this resident or any of the other residents at risk for elopement. Continued interview with the DON revealed that the facility had no formal assessment tool to assess for risk for elopement, and that elopement risk assessments are not required by the facility and had not been conducted. Further interview with the DON revealed that was not aware that the resident attempted to 'catch' doors before they closed, but was aware that he had entered other resident's rooms and was known to observe staff entering the code to open the secured doors. Interview on [DATE] at 1:27 p.m. with the Georgia Bureau of Investigation's officer YY who confirmed that resident's remains were located on [DATE] by the Sheriff's department a short distance from the facility with no apparent foul play involved. Interview on [DATE] at 1:35 p.m. with Certified Nursing Assistant (CNA) EE who reveals she noticed the resident was not in the dining room in his spot and that his tray was still on the cart and notified R#1's assigned CN[NAME] She also states that she noticed the air conditioning contractors working because you could see them out the dining room window. She confirmed that activities are performed in the dining room and that the resident would have been able to see the air conditioning contracted staff working during activities. Interview on [DATE] at 1:45 p.m. with Engineering and Safety Manager QQ who confirmed that contractors were at the facility on [DATE] between the hours of 9:45 a.m. and 11:45 a.m. working in the attic on the air conditioners. Engineering and Safety Manager QQ also confirms that contractors are allowed to work unsupervised by facility staff. Interview with Maintenance Director NN on [DATE] at 3:15 p.m. revealed that the contractors entered into the attic opening to repair the drip pans on the AC. The gate was open for them to go back and forth for supplies, etc. The Maintenance Director stated that he told the contractors not to let anyone out and cautioned them regarding the residents. The gate was rolled closed, but not locked. Post investigation interview with the Administrator on [DATE] at 11:29 a.m. revealed that Engineering and Safety Manager QQ stated that he is the Regional Manager and is at this facility periodically. As the Safety Manager, he attended the Quality Assurance and Performance Improvement (QAPI) meeting on [DATE] that discussed when R#1 eloped and that is when he became familiar with R#1 and was told that the resident had been known to observe the door codes. Post survey interview on [DATE] at 10:34 a.m. with the owner of the HVAC company revealed that they arrived at the facility around 10:00 a.m. and completed their work at 12:00 p.m. He stated that they saw and spoke to no residents while they were working. The HVAC owner revealed that once they were completed he walked to the Administrator's office with the invoice and let her know they were finished. He stated that he walked back towards the dining area to use the that door to exit and the door had a key pad and needed a key code. A nurse was near-by and the nurse quietly told him the code to the key pad to exit out of the door. The HVAC owner stated that no residents were near him or the nurse when he had asked for and was given the code to the key pad. He revealed that when he exited the facility he did not see anyone outside. The HVAC owner revealed when they exited the gate that surrounds the facility they locked the gate before leaving the grounds. The facility implemented the following actions to remove the Immediate Jeopardy: Emergency Preparedness for Missing Patient Implemented on [DATE] by Administrator. 1. On [DATE] at 3:15 p.m., the Director of Nursing and Assistance Director of Nursing made rounds and made sure that every patient was accounted for. 2. On [DATE], the Director of Nursing, Assistant Director of Nursing, RAI Director, and both Resident Care Coordinator's recognized all patients who were at high risk for elopement. A current resident listing was printed and an elopement assessment was completed on each patient to determine if the patient was at high risk, medium risk, or low risk for elopement. 3. On [DATE], the Director of Nursing, Assistant Director of Nursing, and RAI Director reviewed care plans for every patient in the center and started making revisions where necessary. On [DATE], the RAI Director finished necessary care plan revisions. 4. On [DATE], the Administrator, Director of Nursing, and Regional Vice President held a mandatory staff meeting at 7:00 a.m. Education was provided to staff on how to determine the difference between wandering and elopement, realistic goals and interventions for wandering and elopement, causes and risks of wandering and elopement, identifying and care planning those at risk for wandering and elopement, safety and security for those at risk for wandering and elopement, elopement drills, appropriate purpose and use of alarmed doors and exits (there are a total of 7 entry/exit doors). All exit doors currently have a keypad that requires a protected key code to be entered in order to exit the center. Codes are changed monthly and as needed. Use of alarm placed on door that is suspected patient exited (if alarm were to sound, employee is to go with another employee to complete rounds of the outside of building to verify no one left the building, come back inside of the facility and account for every patient to ensure no one exited building), emergency preparedness in the event of a missing person, zone defense rounds (defense rounds include a list of every patient and all 7 entry /exit doors. The nurse assigned to the resident will verify that the resident is accounted for and the gates will be divided among the 2 nurses to be checked and validated as secure), ensuring all safety measures are in place (doing rounds to ensure all gates are locked and doors are secure, and CNA care plan utilization (CNA care plan specifically for CNA's, example: Do they have a walker? Do they require assistance in toileting? 4 of 5 RNs, 13 of 14 LPNs, 28 of33 CNAs, 7 of 7 Dietary, 7 of 9 Housekeeping, 1 Service Director, 1 of 1 Financial Controller, 1 of 1 Human Resource Manager, 1 of 1 Admission Coordinators, 1 of 1 Administrator, and 1 of 1 Medical Record Manager have been in serviced, which is 87.2% of total staff. 5. There were staff that were unable to attend due to as needed (PRN) status (1 total), part-time status (3) and unable to attend who are full-time (4 total). These staff will be educated by Administrator, Director of Nursing, or Assistant Director of Nursing on how to determine the difference between wandering and elopement, realistic goals and interventions for wandering and elopement, causes and risks of wandering and elopement, identifying and care planning those at risk for wandering and elopement, safety and security for those at risk for wandering and elopement, elopement drills, appropriate purpose and use of alarmed doors and exits, use of alarm placed on the door where patient is suspected to have exited (if alarm were to sound, employee is to go with another employee to complete rounds of the outside of the building to verify no one has the left building, come back inside of facility and account for every patient to ensure no one exited building), emergency preparedness in the event of a missing person, zone defense rounds, ensuring all safety measures are in place (doing rounds to ensure all gates are locked and doors are secure), and CNA care plan utilization (CNA care plan specifically for CNA, example: Do they have a walker? Do they require assistance in toileting?) 6. Interventions implemented by the facility include: Staff member sat and monitored door #5 that suspected patient exited on [DATE], (log kept) a door alarm was placed on door #5, [DATE]. Administrator and Engineering Safety Manager assessed the building entrances and exits to determine any risk factors for elopement (made sure that all gates were locked and doors were secure), Administrator interviewed the owner of the Heating, Ventilation, and Air Conditioning (HVAC) company on [DATE] and owner stated that he did not see the resident nor speak to the resident and confirmed that the additional 4 HVAC employees did not see or speak to the resident. On [DATE], all door codes were changed. Ad-hoc (impromptu) QAPI meeting held on [DATE] to determine mechanisms for preventing further occurrence (attendants include Administrator, Director of Nursing, Financial Controller, Assistant Director of Nursing, MDS Coordinator, Infection Control Nurse, Education Nurse, Food Service Manager, Social Service Director, Facility Management Supervisor, Environmental Services Supervisor, Patient Care Coordinator, Regional Vice President, Human Resource Manager, Regional Engineering Safety Manager, and Recreational Therapist), Assessments performed on all residents on [DATE]. All residents assessed per DON on [DATE] to determine if any additional residents are at high risk (findings did show that some residents who were previously considered low risk are now considered high risk) and resident specific interventions implemented as needed by RAI Director, on [DATE] RAI Director implemented specific interventions as needed for those residents recognized to be at high risk for elopement (Interventions include: Redirect resident if he/she becomes agitated when possible, Notify MD (DON spoke with him on Friday and discussed doors and QAPI) for further interventions when needed, if resident voices wanting to leave facility notify social services or charge nurse as needed, observe for suspicious behaviors of a possible attempt such as hanging in doorways or pushing on doors, talk with resident and attempt to redirect if noted to be confused about whereabouts as needed, redirect resident if possible, try to determine cause for agitation, involve resident in activities as will tolerate to redirect attention and thoughts, involve in activities such as bingo and music related, activities for diversion, praise resident for good behavior and staff members that resident might relate to better to further interventions, talk with resident about past experiences to provide diversion). Gates are documented checked twice a day to insure all gates are locked. All staff received education on [DATE] presented by the Administrator, Director of Nursing, and Regional Vice President on how to observe gates and make sure gates are locked at all times during the day. Facility follows same protocol for weekends and holidays. There are currently seven entry/exit doors. A temporary alarm was placed on suspected exit door #5 on [DATE], the remaining six doors will have a temporary alarm placed by the close of business [DATE]. Installation of permanent key pads with an alarm that alarms if door is opened longer than thirty seconds or if door is forced open will begin [DATE]. Anticipated completion date is Tuesday, [DATE]. Temporary alarms will remain on doors until all permanent alarms are placed and working. Door alarms are checked hourly during zone defense rounds completed by nurses responsible for residents located on that hall. All doors are locked and have a keypad that requires a protected code in order to be opened. The entire facility is surrounded with a fence that includes locked gates that must be unlocked in order to exit. Gate checks are completed twice a day to insure all are securely locked 7. The Administrator and the Director of Nursing will monitor the collected elopement data (elopement data is gathered from the elopement assessment tool providing information on does the patient attempt to elope? Do you see the patient attempting to get out the doors? Are you aware of the patient leaving the center without informing staff? Does the patient wander aimlessly? Does the patient express the desire to go home? Is the patient easily redirected? Are there any interventions that you find helpful with redirecting the patient when they may be seeking an exit?) Using the Elopement assessment tool (the elopement assessment tool asks the following questions on every resident to determine elopement risk: Do they attempt to elope? Do you see the patient attempting to get out the doors? Are you aware of the patient leaving the center without informing staff? Does the patient wander aimlessly? Does the patient express the desire to go home? Is the patient easily redirected? Are there any interventions that you find helpful with redirecting the patient when they may be seeking an exit?) for 6 weeks and review monthly during QAPI. New admissions and re-admissions will have an elopement risk assessment (elopement risk assessment ask the following: Does this resident have a court-appointed guardian? Does this resident have the cognitive ability to make relevant decisions? Does this resident have a history of escape or elopement? Does the resident have a related diagnosis dementia/depression/mental illness, Does the resident move around freely and independently with or without devices such as he/she wants to leave to go home, wander with or without devices such as he/she wants to 1 eave to go home, Does the behavior include risky behaviors such as trying to open doors) completed on him/her at time of admission to facility. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Interview with the Director of Nursing (DON) and (Assistant Director of Nursing (ADON) on [DATE] at 11:45 a.m. revealed that when R#1 was suspected to be missing from the facility on [DATE], Nursing made rounds and ensured that every patient was accounted at 3:15 p.m. Documentation was provided verifying that rounds were made at that time and that every resident excluding the eloped resident was accounted for. 2. On [DATE], the Director of Nursing, Assistant Director of Nursing, Resident Assessment Instrument (RAI) Director, and both Resident Care Coordinator's reviewed all residents who were at high risk for elopement. A current resident listing was printed and an elopement assessment was completed on each resident to determine if the resident was at high risk, medium risk, or low risk for elopement. An interview conducted on [DATE] at 10:38 a.m. with the Director of Nursing, Assistant Director of Nursing, and the Resident Assessment Instrument (RAI) Director and who confirmed that all facility residents were assessed for elopement risk. A current resident listing was provided and Record review revealed that an elopement assessment had been completed on every resident to determine if the resident was at high risk, medium risk, or low risk for elopement. 3. On [DATE], a current resident listing was printed and an elopement assessment was completed on each patient to determine if the patient was at high risk, medium risk, or low risk for elopement. A current resident listing and elope assessment risk for every patient in the center was provided on [DATE] at 10:38 a.m. On [DATE], the Resident Assessment Instrument (RAI) Director finished necessary care plan revisions and provided copies of the care plan revisions for residents assessed as high or medium risk. 4. A meeting was held with Administrator, Director of Nursing, Regional Vice President, Resident Assessment Instrument (RAI) Director coordinator on [DATE] at 10:35 a.m. who confirmed their presence in this meeting or that they were reached by telephone and that how to determine the difference between wandering and elopement, realistic goals and interventions for wandering and elopement, causes and risks of wandering and elopement, identifying and care planning those at risk for wandering and elopement, safety and security for those at risk for wandering and elopement, elopement drills, appropriate purpose and use of alarmed doors and exits. Summary of the training tool was provided for reference. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related to determining the difference between wandering and elopement, about goals and interventions for wandering and elopement, the causes and risks for wandering and elopement, identifying and care planning residents that are at risk for wandering and elopement, providing safety and security for those at risk for wandering and elopement, elopement drills, the appropriate purpose and use of alarmed doors and exits, what to do if a door alarm does alarm, what to do in the event of a missing person, zone defense rounds, ensuring all safety measures are in place including rounds to ensure all gates are locked and doors are secure, and utilizing the CNA care plans. These interviews were conducted on [DATE] as follows: LPN UU at 8:30 a.m., LPN VV at 8:45 a.m., CNA WW at 8:50 a.m., RCC Nurse Supervisor XX at 9:00 a.m., CNA YY at 9:40 a.m., LPN ZZ at 9:45 a.m., LPN AAA at 9:50 a.m., CNA BBB at 9:55 a.m., CNA CCC at 10:00 a.m., CNA DDD at 10:05 a.m., CNA EEE at 10:10 a.m., LPN FFF at 10:15 a.m., CNA GGG at 10:20 a.m., CNA HHH at 10:25 a.m., CNA III at 10:30 a.m., Housekeeper JJJ at 8:55 a.m., Housekeeper KKK at 9:00 a.m., Maintenance LLL at 9:05 a.m., Activity Director MMM at 9:10 a.m., Social Services NNN at 9:15 a.m., Human Resources OOO at 9:20 a.m., Medical Records PPP at 9:25 am, CNA QQQ at 10:35 a.m., CNA RRR at 10:45 a.m., CNA SSS at 10:45 a.m., Dietary Aide TTT 10:50 a.m., Dietary Aide UUU at 10:55 a.m., ADON DD, RAI Coordinator EE, Admissions FF, Human, Resources GG, Financial Controller, HH, RCC II, Activity Director KK, Social Services LL, Maintenance NN at 11:00 a.m. Record review of in-service sign in sheets revealed that 68 staff attended this in-service and 10 staff did not attend and were educated via phone by Administrator. Door codes for 7 doors (all facility exit doors) were changed on [DATE] at 3:00 p.m. Monthly code changes were confirmed during interview with Regional Engineering and Safety Manager on [DATE] at 12:10 p.m. and were again confirmed by the facility Maintenance Director on [DATE] at 10:38 a.m. Observation revealed that the temporary alarm mounted on door #5 was functional for both access and egress. Tour of the Gate perimeter and door rounds with the facility Maintenance Director on [DATE] 10:38 a.m. confirmed that gate rounds are made hourly and keypad doors have been monitored and recorded since at least (YEAR). Code changes are made monthly or as needed and are recorded. Both the Regional Engineering and Safety Manager and the Maintenance Director were able to articulate the new Zone Access Tool process and support this new tool. Interview on [DATE] at 9:50 a.m. the DON with who confirmed that Door #5 that an alarm was placed on door #5 on [DATE] at 2:05 p.m. and that the alarm is functional. Staff have been trained in the new Zone Defense tool and know what to implement if the alarm were to sound unexpectedly. An interview on [DATE] at 9:55 a.m. with LPN RR who revealed she would go with another employee, complete rounds of the outside of building to verify no one left building and come back inside and account for every patient to ensure no one exited building. She was able to explain emergency preparedness in the event of a missing person, zone defense rounds (defense rounds include a list of every patient and all 7 entry/exit doors. The nurse assigned to that resident will verify that the resident is accounted for and the gates will be divided among the 2 nurses to be checked and validated as secure), ensuring all safety measures are in place (doing rounds to ensure all gates are locked and doors are secure). CNA's also participate and are responsible for care plan utilization of the CNA care plans, like identifying if the missing resident uses a walker, can walk unassisted, has a beard, etc. 5. Of the staff unable to attend on [DATE], two were on medical leave, one is a PRN employee, and three are part time and did not attend. All of these employees have since been trained as of the end of the day on [DATE]. This is evidenced by the sign in sheets and confirmed with interviews on [DATE] with the Director of Nursing and Assistant Director of Nursing on [DATE] at 10:38 a.m. 6. Review of the log book reveals that door #5 was secured and monitored until the door alarm was placed on [DATE] at approximately 5:00 p.m. In the event of a missing person, emergency preparedness zone defense rounds are initiated that include a checklist of every patient and review of all 7 entry/exit doors. The nurse assigned to that patient will verify that patient is accounted for and the gates will be divided among the 2 nurses to be checked and validated as secure), ensuring all safety measures are in place including rounds to ensure all gates are locked and doors are secure, and CNA care plan utilization such as specific resident CNA care plans: Does resident have a walker? Do they require assistance in toileting? Observation of Mock zone defense rounds on [DATE] beginning at 8:30 a.m., at 9:25 a.m. and again at 10:10 a.m. revealed that participating staff included housekeeping JJJ, KKK, LPN's Z, and AAA, CNA FFF, and activity director DD, maintenance LLL. Other staff observed and were asked questions about the process. Staff who were unable to participate were called and interviewed over the phone for the Zone Defense Tool including the following questions: in the event of a missing person, what protocol is followed? When are emergency preparedness zone defense rounds initiated and what do they include? Is there a check list of every patient and review of all 7 entry/exit doors? What does the nurse assigned to that patient do, how are the gates divided, checked and validated as secure? After all safety measures are in | 2020-09-01 |