LIVINGSTON, TX- TIMBERWOOD NURSING AND REHABILITATION CENTER

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30664

Based on interview and record review, the facility failed to ensure each resident received adequate
supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accidents and supervision. (Resident #1)

The facility failed to provide adequate supervision for Resident #1 who was assessed as a high risk for elopement. On 01/22/24 he was allowed to sit on the front porch without supervision, and facility was contacted by equipment company next door that resident was there.

The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 01/22/2024 and ended on 01/22/2024. The facility had corrected the non-compliance before the survey began.

This failure could prevent residents from receiving appropriate supervision which could lead to resident sustaining serious injury or harm.

Findings included:
Record review of an undated face sheet indicated Resident #1 was a [AGE] year-old male admitted on [DATE]. His diagnoses included congestive heart failure systolic and diastolic (a condition in which the heart’s main pumping chamber (left ventricle) is weak, becomes stiff, and unable to fill properly), respiratory failure (a serious condition that makes it difficult to breathe on your own), hypertension (a condition in which the force of the blood against the artery walls is too high), atrial fibrillation (a type of irregular heartbeat), and cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off).

Record review of hospital records with a History and Physical dated 01/12/2024 indicated Resident #1 had a history of methamphetamine abuse.

Record review of an Elopement/Wandering Evaluation dated 01/19/2024 indicated Resident #1 was a high risk with a score of 25 out of 55. The form was signed by LVN B.

During an interview on 09/11/2024 at 11:43 a.m., LVN B said she had filled out the
Elopement/Wandering
Evaluation on Resident #1. She said she answered some of the questions based on the personal
history of knowing Resident #1 and his drug abuse history and that was why it triggered him at high
risk for elopement.

Record review of a Brief Interview for Mental Status dated 01/22/2024 indicated Resident #1 had
severely impaired cognition with a score of 04 out of 15.

Record review of Progress Notes with a Nursing Note entry dated 01/22/2024 indicated Resident #1 had been at the nurses’ station multiple times today asking to call his de-identified family
member. RN A was able to get her on the phone for him and he was able to speak with her. After
speaking with her, Resident #1 asked if he could leave the facility to go to the bank. RN A told
him yes, he could but he needed to sign out and have a ride to take him and he stated that someone
was going take him to the bank and he would be back in two hours. He then walked towards the front. RN A told him once again to let the nursing staff know that he was leaving and to come sign out. Resident #1 verbalized understanding.

During an interview on 09/11/2024 at 11:17 a.m., RN A said Resident #1 came to the nurse station
wanting to go the bank to get some money. RN A said she contacted the de-identified family member and Resident #1 spoke with de-identified family member on the phone. RN A said then Resident #1 went to the resident phone and had called someone. RN A said Resident #1 then came back to the desk and asked could he leave the facility to go to the bank and RN A told him yes but needed to sign out and have a ride to take him. RN A said he had a ride to take him and walked towards the front at which point she reminded him to let them know he was leaving and to come sign out.

A Provider Investigation Report dated 01/30/2024 indicated the incident occurred on 01/22/24 at
01:00 p.m Resident #1 went on the front porch to sit and wait for a ride. He then unknowingly left
the facility walked next door to a local business to ask for a ride to the bank. The facility
initiated the elopement protocol when they realized he was not in the facility. The grounds were
searched. Resident #1’s de-identified family member was contacted who said she had not picked him up. During the search the local business contacted the facility to let them know Resident #1 had walked next door and asked for a ride to the bank. The Administrator and DON picked up the resident and returned him to the facility. A head-to-toe assessment was conducted with no negative findings. His de-identified family member was notified he was back at the facility and one on one monitoring was initiated. His physician arrived at the facility and assessed him with no negative findings. In-services were conducted with staff on elopement protocol, on accuracy of elopement assessments, and on residents sitting out front. All residents had updated elopement assessments conducted. The Elopement Binder was updated. Resident #1 continued on one-on-one monitoring until he was transferred to a secured unit facility.

During an interview on 09/11/2024 at 02:18 p.m., the DON said they reviewed the camera on the front porch and it was approximately 10 minutes from the time Resident #1 started walking down the driveway to when the local business next door notified them the resident was at their business.

Record review of a Physician/NP/PA Progress Note/Discharge Summary dated 01/22/24 indicated
Resident #1’s physician examined the resident and indicated .clinically stable. continue lasix and atenolol. cardiac diet reviewed. ok for [discharge] home. [follow up] with [primary care physician] and cardiology within a week after [discharge]. [emergency room ] warnings reviewed for chest
pain/[shortness of breath]

Record review of 15-Minute Checks form indicated Resident #1 was observed every 15 minutes from
after he returned to the facility on [DATE] until he discharged to another facility on 01/25/24 at
05:45 p.m

During an interview on 09/11/24 at 03:22 p.m., the DON said when Resident #1’s physician examined him, he said Resident #1 could go home. She said she explained to the physician that Resident #1’s de-identified family member did not want him to go home because of the drug abuse and his de-identified family friend was not a good influence. She said she told the physician the
de-identified family member had the keys to Resident #1’s home and would not give them to the
facility or to the resident. She said at that time the QAA committee including Resident #1’s
physician who was the Medical Director reviewed everything. They decided to reeducate everyone on elopement, on accuracy of elopement assessments, and on residents sitting out front; assess all
residents for elopement; update the elopement binder; Resident #1 was to be transferred to a
facility with a secured unit; and he was to remain on one-on-one monitoring until his transfer. She
said the information was all put into the QAPI report. She said Resident #1’s de-identified family
member was notified, and the de-identified family member agreed to the transfer.

Record review of a policy with revision date of 12/2023 titled Elopement/Unsafe Wandering indicated Policy: It is the policy of this facility to provide a safe environment, as free of accidents as
possible, for all residents through appropriate assessment, interventions, and adequate supervision
to prevent accidents related to unsafe wandering or elopement while maintaining the least
restrictive manner for those at risk for elopement. Definitions: Elopement occurs when a resident
leaves the premises or a safe area without the facility’s knowledge, authorization (i.e. an order
for discharge, appointment, or leave of absence), and/or any necessary supervision to do so.
Procedure: 1. Residents with capabilities of ambulation and/or mobility in wheelchair will have an
Elopement/Wandering Evaluation completed to determine risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempts to elope. 2.
Residents with high risk factors will be identified as At Risk and will have an individualized care
plan developed that includes measurable objectives and timeframes

Record review of an In-Service Attendance Record with subject of Elopement Drill and Procedure,
dated 01/22/2024, indicated that 57 staff members signed the in-service record including RN A, LVN B, and Receptionist C.

Record review of Assessment History LN-Elopement/Wandering Evaluation list dated 01/22/24 at 04:44 p.m. indicated all residents in the facility were reassessed on 01/22/24.

Record review of Incident logs from 01/22/24 through 09/12/24 indicated there were no other
resident elopements from the facility.