Integrity Hc Of Marion

wearing a wander guard at that time. V6 stated R1 was a risk for elopement, but he had never tried to leave the building before. V6 stated R1 would pack his things and say he was leaving with his family but never tried to exit. V6 stated his family brought R1 back later that evening.On 11/6/25 at 2:05pm, V7 (LPN) stated she was working 100 hall, and R1 was on 200 hall at the time of the elopement. V7 stated she remembered R1 asking for a tray, which was unusual and then about 20 minutes later they noticed he was missing. V7 stated to her knowledge the wander guard system was working.On 11/6/25 at 2:15pm, V8 (CNA/Certified Nursing Assistant) stated he was working the day that R1 eloped. V8 stated it was around 3:00pm the nurse noticed R1 was missing and made everyone check all the rooms and the outside of the facility multiple times and then the police were called. V8 stated V6 (LPN) had already had staff keeping an eye on R1 because he had been restless that afternoon.On 11/6/25 at 2:56pm, V3 (Regional Director of Clinical Services) stated they immediately reassessed R1's elopement risk, moved him from the 200 hall to the 400 hall and put a electronic monitoring device on him. V3 stated they had identified the problem and already had a plan of correction in place.The facility policy titled Elopements, with a revision date of 2/2025, documents in the section titled policy statement Staff shall investigate and report all cases of missing residents.

Prior to the survey date, the facility took the following actions to correct the noncompliance:QAPI (Quality Assurance and Performance Improvement) committee met on 10/20/25 with V1 (Administrator), V2 (Director of Nursing), and V3 (Regional Director of Clinical Services) in attendance.

The QAPI Ad Hoc form notes documents as follows:1. R1 was immediately located and returned safely to the facility.

Resident was assessed head to toe upon return, no injuries were noted.

Vital signs stable.

Physician and responsible party were notified of incident.R1 elopement risk status and interventions have been updated.Counseling and education provided to all staff involved regarding elopement prevention and response protocols.2,The Social Services Director will conduct a facility-wide audit of all residents with elopement risk factors or active elopement care plans.Reviewing of staff rounding and supervision schedules in all high risk areas.3.

Facility immediately re-educated of all staff on facility Elopement Prevention and Response Policy.Facility immediately initiated an elopement investigation and placed safety interventions and care plan updated for R1.Interdisciplinary team to review all elopement incidents and near misses during QAPI meetings to identify trends.4. V2 or designee will complete weekly audits 5 times a week for 4 weeks, then monthly x 3 months to ensure: Elopement risk assessments and care plans are current.

Staff are following elopement interventions and protocols. If trends or concerns are identified, additional corrective actions and staff education will be implemented.5.

Ongoing monitoring through QAPI tracking logs and Performance Improvement meetings to evaluate effectiveness and sustain improvement.

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