Whitesboro Health And Rehabilitation Center

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

do in an emergency such as elopement or potential elopement. She stated it was important to follow protocol to find the resident as soon as possible and ensure the resident was safe. The DON stated staff did what they were supposed to do and did it well. She stated it was something they did not do often and that was a different situation. The DON stated the resident was found within the 30 minutes of staff noticing

she was missing. The DON stated Resident #1 told staff the [NAME] told her to get out of the building and when staff located her, she refused to go back into the building. She stated the nurse assessment revealed no physical injury. The DON stated the emergency medical services took Resident #1 to the hospital for evaluation. The DON printed Resident #1's hospital record which showed she was admitted for hallucinations and hypertension. The DON stated the resident would return on 1:1 monitoring.Interviews on 10/22/2025 between 1:42 PM and 5:40 PM were conducted with multiple staff members which included the Administrator, DON, Regional Compliance Nurse, ADON, Social Worker, RN A, CNA B, MDS Coordinator, Business Office Manager, Housekeeping Supervisor, LVN C, LVN D, CNA E, CNA F, CNA G, LVN I, Housekeeping Staff and CNA K. Interviews revealed staff members received elopement in-service training and participated in elopement drills. Staff were reminded to be alert to signs of exit seeking and to notify the charge nurse or DON to assess the resident as needed. Staff members were educated on their role when a code orange (elopement) was called in the facility. The elopement drills included the designation by the charge nurse of staff members to an assigned search area which included searching every room in the facility to ensure the resident was in the building and safe. If a resident was not located inside or outside the building, police, family, and the physician must be notified. No lack of knowledge or procedure was identified. The facility initiated the following interventions prior to the state surveyor entry on 10/21/2025:Record review of Resident #1's clinical file on 10/22/2025 at 10:15 AM reflected the following:-Resident #1's risk assessment on 10/04/2025 reflected the resident was not a high risk for elopement. The elopement risk assessment completed on 10/20/2025 indicated the resident was at high risk.-Resident #1's Comprehensive Care Plan was updated with interventions on 10/20/2025 after the resident exited the building.-Elopement risk assessments and care plans were updated on all residents in

the building on 10/20/2025. -The Medical Doctor, Psychiatrist, Director of Nursing, Administrator, and Resident #1's family member were notified of the elopement on 10/20/2025. -Documentation of education of all staff on resident rights, abuse, neglect, and exploitation beginning with night shift staff on 10/20/2025. -Documentation of education of all staff on elopement prevention and response, exit seeking, and door protocols beginning with night shift on 10/20/2025.-Documentation of elopement drills initiated on 10/21/2025 and to continue three times weekly following the elopement.- Documentation of an hourly monitoring log initiated on 10/20/2025 to ensure all residents' windows were intact until window alarms installed- Documentation of a facility work order, dated 10/21/2025, for alarms to be installed on all residents' windows - Documentation of door alarm or lock function monitoring 5 times weekly for each exit door was initiated on 10/20/2025.Administrative staff were observed conducting window checks in the residents' rooms on 10/22/2025 at 10:00 AM, 11:00 AM, 12:00 PM, and 1:00 PM. The work order was completed and the residents' windows equipped with window alarms prior to the surveyor's exit. Record

review of the facility's policy Elopement Prevention, undated, reflected Every effort will be made to prevent elopement episodes while maintaining the last restrictive environment for residents who are at risk for elopement. Record review of the facility's policy Elopement Response, undated, reflected Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented.

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