Lafayette Manor, Inc

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

home] and down elevator to lower level. Resident has no history of elopement/elopement attempts from home/previous facility/current facility. Review of an employee statement written by PCA Employee E3 dated 1/6/26, indicated, On 1-6-26 at 9:50 pm, I just started to walk in [Assisted Living Facility] to start work and I saw workers looking for someone who was missing. I went to clock in and found missing client sitting down by clock in the basement. I then took her upstairs and [facility] was notified that she was found. Review of

an employee statement written by Nurse Aide Employee E1 dated 1/7/26, indicated, I went in to check on

the resident I seen her about 20 minutes before l'd say around 9:10. I kept checking in on her because she kept getting up we all aides kept redirecting her back in her room. I went in her room around 9:30 to check

on her and do her inventory sheet and she wasn't in her bed. I looked in the bathroom she wasn't in there I checked residents room she wasn't there I then yelled and said resident is missing I need help everyone then got up and started looking. I doubled checked gold hall then went to the basement checked the laundry room the fire exits where we keep supplies. I ran back upstairs to get my phone because its pitch dark outside. I checked the little rooms that was open went outside checked the back the rooms ran around

the building went by the [other buildings on campus] was everywhere I could walk. I walked back up they said they found her in the basement. The RN had us do a head count. I did blue hall all 10 residents was accounted for and also my other 4 was accounted for after we found her. On 1/6/26, the facility initiated a plan of correction that included:-Immediate count of all facility residents.-Elopement assessment completed.-Application of a Wanderguard (security bracelet that alerts when an identified resident approaches a monitored door).-Update to Resident Resident R1's baseline care plan.-Audit of all facility residents for elopement risk.-Update of elopement binders located at the front desk and the first and second floor nurses' stations.-Education for all licensed nursing staff on resident orientation to the facility, admission audit tool, and admission policy.-Education for all staff on the facility elopement policy and elopement prevention.-Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting, with resolutions to purchase/install concave mirrors and complete audits.-Audits of admissions to be completed by Director of Nursing or designee five times per week for four weeks, to be reviewed at next QAPI meeting. Review of Resident Resident R1's clinical record completed on 1/28/26, revealed the elopement assessment and care plan had been updated to include information on his elopement, risk for further elopement, and interventions. During four interviews on 1/28/26, licensed nurses confirmed they received education on resident orientation to the facility, admission audit tool, and admission policy. During eight interviews on 1/28/26, staff confirmed they received education on elopement prevention and procedures if an elopement occurs. During an interview

on 1/28/26, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of five residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

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