Golden Glades Inspection Report 12/11/2015

DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED:2/14/2018
CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED

OMB NO. 0938-0391
STATEMENT OF (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
DEFICIENCIES / CLIA A. BUILDING ______ COMPLETED
AND PLAN OF IDENNTIFICATION B. WING _____ 12/11/2015
CORRECTION NUMBER
105469
NAME OF PROVIDER OF SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
GOLDEN GLADES NURSING AND REHABILITATION CENTER 220 SIERRA DRIVE
MIAMI, FL 33179
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0224 Write and use policies that forbid mistreatment, neglect and abuse of residents and theft
of residents' property.
Level of harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
jeopardy Based on observation, interview and record review, the facility failed to ensure they provided services necessary to avoid
physicial harm for one (resident #1) of 14 sampled residents that resulted in neglect. The facility identified 3 current
Residents Affected - Few residents at risk for elopements and three of the 14 sampled residents were at risk for elopements. The facility failed to
ensure adequate supervision in a safe and secure environment to prevent the resident's elopement from the facility. These
failures potentially resulted in the death of resident #1 who was cognitively impaired and had a history of [REDACTED].
These failures included, but were not limited to: 1) Prior to this resident's death, the facility did not utilize staffing
adequately nor have adequate policies, procedures, and staff oversight that would allow appropriate supervision of
residents and their activity after 8:30pm. 2) The facility also did not identify a potentially harmful environmental hazard
by having a damaged low gate that was the only barrier between the facility and a large body of water. The environmental
hazard also included, the facility didn't have a system to adequately address the exit door alarms on the first floor. This
neglect resulted in the determination of immediate jeopardy to the health and safety of the residents. There were 175
residents residing in the facility. The immediate jeopardy was removed on [DATE].
Cross Reference to F323 and F490.
The scope and severity of F224 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is
not immediate jeopardy as of [DATE]. The scope and severity was lowered as a result of the facility's corrective actions
implemented as of [DATE]. These corrective actions were verified by the survey team through observation, record review and
interview.
Findings included:
Record review revealed a Federal Immediate Report submitted to AHCA (Agency for Health Care Administration. The report
indicated the type of incident was neglect. The description of the incident included: 10:46 pm on [DATE] resident (#1) was
noted not in room or on common grounds at time of rounds. All units were notified and staff immediately conducted a
thorough search of the facility grounds, property, and searched a one to two mile radius. After the search, law enforcement
was contacted, they visited the facility and a report was completed. The resident's physician was present in the facility,
Administrator and Director of Nursing. A message was left for local County Guardianship. The report indicated the State
Abuse Registry was notified on [DATE]. Review of the Federal Five Day Report submitted to AHCA indicated the facility was
informed on [DATE] at 3:00 pm by an employee from an ALF (Assisted Living Facility) that there is a body observed in the
lake behind the ALF. Immediately upon notification the facility contacted 911 and Fire Rescue. The Police proceeded to
initiate their investigation. At approximately at 10:30 pm on [DATE], the body was identified as resident (#1). The
facility's corrective action included, adding additional staff above the required ratio, staff have been added across all
three shifts. Additional staff have been added to ensure no additional residents leave without facility or physician
approval. All staff have been re-in serviced on abuse, supervision and elopement policies. The Nurse and C.N.A. (certified
nursing assistant) assigned to resident on the ,[DATE] shift on [DATE], were suspended pending a risk management and
administrative determination.
Record review revealed an Investigative Summary submitted by the Department of Children and Families (DCF) which included
the following sequence of events: [DATE] at 9:26 pm Resident (#1) is a vulnerable adult due to the fact that he has an
unspecified cognitive impairment, cardiac arterial disease, [MEDICAL CONDITIONS], hypertension, and a chronic medical
condition. On [DATE], he was discovered missing from the 3rd floor where he was last seen around 11:00 pm. He was under
regular monitoring, which means that he is checked on by staff every two hours. The facility is not a locked facility. It
is unknown how he was able to get by security and a gate in the front of the facility. He has a legal guardian. On [DATE]
at 10:04 pm Resident (#1) is a vulnerable adult who suffers from cardiac problems, hypertension, cognitive impairments,
depression and a chronic medical condition. Due to his cognitive impairment he is very forgetful and easily confused. There
is a concern for resident (#1) because unbeknownst to staff he went missing on [DATE]. The staff does not know what time he
left the facility, but he was noted missing around 11 pm. Although the facility is not a locked down facility, after hours
the only doors that are unlocked are the front doors. There was a security guard on duty from 7 pm until 7 am on the day he
went missing. A missing person's report was filed with law enforcement at 11:30 pm on [DATE], but his whereabouts were
still unknown. On [DATE], Resident (#1) was a vulnerable adult due to [MEDICAL CONDITION] with a history of Dementia and
Paranoia. He was discovered missing from the facility at 3:00 am on [DATE]. He left the facility unattended and as a result
he was found drowned on [DATE]. The facility was unable to explain how he was able to get out of the facility. He was found
in a lake near the facility. In order to leave the facility you must be buzzed out to leave by staff. He had no history of
leaving the facility.
During interview via telephone with the DCF investigator on [DATE] at 1:58 pm, it was reported, the final DCF report was not
completed as final interviews must be conducted. The investigator reported, The facility told me the resident was seen
around 10:30pm or so. Shift change is at 11:00 pm. During the 11:00 pm rounds he was not present when the staff was trying
to account for all the residents. A search was started immediately in the facility, the grounds, and the neighborhood. The
police were called during the time of the search. He was not found until the following day. The staff said the facility is
locked at that time of night. There is a security guard at the front door and the gate should be locked.
Observation on [DATE] at 8:00 pm upon entrance to the parking area revealed, a closed gate which opened via electronic
activation when the car approached the gate. There was also a gate to exit the parking area which was closed. When the
gates were approached on foot from inside, they would not open. A security guard was posted next to the front door outside
the facility. There were approximately 12 residents sitting outside in the smoking area. There was a fence at the end of
the smoking area which was secured with chains and a combination locks. There was also a fence surrounding a lake on the
East end of the building. There was an area at the end of the fence where the gate was damaged and had been secured with a
second piece of fencing. This area was not visible where the security guard was positioned. This area could be accessed
near the dumpster area and is not accessible from the front area of the building or through the front door. The only way to
access this portion of the grounds is through the East Wing exit door.
Observation on the first floor on [DATE] at 8:20 pm revealed, a Certified Nursing Assistant (CNA) at the West Wing exit
door. This door was locked and required a code to exit the building. The door also had a sign that read push until alarm
sounds - door can be opened in 15 seconds. The door at the opposite side of the building (East Wing) in the hall that leads
to the kitchen and laundry area had had an alarmed double door with a key pad. A sign on this door read push until alarm
sounds - door can be opened in 15 seconds. The handle of the door was pushed, the alarm sounded. After 15 seconds, the
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

REPRESENTATIVE'S SIGNATURE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99) Event ID: YL1O11 Facility ID: 105469 If continuation sheet
Previous Versions Obsolete Page 1 of 11
OMB NO. 0938-0391
CORRECTION NUMBER
105469
MIAMI, FL 33179
F 0224 (continued... from page 1)
surveyors passed through the door. There was no staff that responded to the alarm. At the end of the hallway, the door to
Level of harm - Immediate the outside was unlocked and there was a C N A positioned at the door.
jeopardy During interview with a Licensed Practical Nurse (staff I) on [DATE] at 9:00 pm, she reported, report is done with my relief
between 11:00 pm and 11:15 pm. Walking rounds are done with the oncoming shift. Staff I stated, last Tuesday ([DATE]) the
Residents Affected - Few staff came up to this floor looking for resident (#1). We searched every room on this floor including the resident rooms,
bathrooms, and the dining area. I do not remember exactly what time this happened, but I remember that I was passing my
9:00 pm medications so it was between 8:30 and 9 pm. After I finished my medications, I went downstairs to see if he was
found and they said no.
During interview with a Licensed Practical Nurse (staff C) on [DATE] at 9:17 pm, she reported, she works different shifts,
but her primary shift is the ,[DATE]pm shift. The procedure when I arrive is to do a walk through to check every room to
check to make sure everyone is alive and well and in good condition. At the end of the shift the same thing is done with
the oncoming nurse. I also have to make rounds at least every 2 hours. The C N A's also do walking rounds at the beginning
and end of each shift. They are responsible to visibly see each patient. If not, they report to the nurse. One day last
week, we could not find a patient. I was the ,[DATE] supervisor that night. I was making rounds on the 3rd floor. I saw the
patient about 9:30 pm - 10:00 pm. He was at the nurse's station downstairs on the 3rd floor, and then at one point he was
walking to his room. Since he was going towards his room, I left the floor to make rounds on another floor. I went back to
the 3rd floor at about 10:,[DATE]:45 pm. I made rounds on the unit and the CNA's were making their last rounds. He was not
in his room at that time. He was a very tall 6 foot man. We started to search the floor. We searched the entire floor room
to room and could not find him. The 2nd and 4th floors were also searched. We checked the outside smoking area and asked
everybody that was downstairs. We spoke to other residents and the security guard and nobody saw him. After searching the
grounds, I circled the block in my car. I called the DON and she said he has to be on the grounds, look around some more.
After searching the grounds again, I called the DON back and she instructed me to call the police (11:30pm - 12:00am). The
police arrived and implemented a search. This gentleman was alert, but confused. He was ambulatory, but walked very slowly.
He was a tall elegant man. He would spend a fair amount of time outside in the smoking area and walking about the grounds.
He liked to talk to people. There are three exits downstairs, the front door and two side doors. The side doors have
alarms. Just the front door can be accessed in and out. The exit door by the kitchen requires a code to get out. The other
door at the end of the hall is locked at a certain time. It also has a code. The main door is the front door. Security is
here around the clock. The gate is also locked at night and you have to have a vehicle to get out. He could not have gotten
out through the gate. I checked the local hospitals and looked everywhere. He was found right outside the facility. I was
not here when he was found. Nobody has any idea how he got out the entire area is secured.
During interview with a Licensed Practical Nurse (staff F) on [DATE] at 9:52 pm, she reported, she was working on this floor
(3rd) on the East side last Tuesday on the ,[DATE] shift. What I recall is that the nurse was doing her last medication
pass around 9:00 O ' clock. (West Wing). Before she got to the resident (#1) with medication, the CNA told the nurse she
could not find this resident. He was not in his room (#323 M). We checked each room on the 3rd floor and called the
supervisor. All the rooms in the building were searched. The grounds outside were searched, but it is dark outside. We also
were sent out in our cars to look for the resident. It is pitch black outside, I am not sure if there are any lights
outside, but it is very dark. He was alert with some mild confusion, but was easy to redirect. He would follow direction
for short periods of time. He was allowed to go outside by himself. At times he would go outside and then come back. I am
not aware that he had a history of [REDACTED]. We checked the back parking lot by the dietary end. The gates in the front
are locked at all times, but we went out looking anyway. There is a fence by the smoking area that is also locked at all
times. We also have a double pad lock on the door at the end of the hall by the kitchen. There is a double door that
requires a key pad to get through. The door at the end of the hall has no lock. It is supposed to be secured at the first
set of double doors. There are alarms at the end of the hallway for each door on the floors, but the double doors
downstairs are not alarmed. You can not open the door without knowing the code. They now have staff at every door. This
started the same day. There is now a CNA at the two exit doors in the hall. This is a new protocol that started after the
incident. We have security ,[DATE]. They patrol the whole front area and the parking lot. This resident was not found until
the next day.
Observation on the 1st floor East Wing on [DATE] at 10:15 pm revealed, the double doors that led to the hallway to the
kitchen and laundry area. The sign on the door read, push until alarm sounds - door can be opened in 15 seconds. There was
also a key pad to open the door. Surveyors engaged/pushed on the door, the alarm sounded for 15 seconds and then the door
was opened. There was no staff observed responding to the alarm. The maintenance director was close by, but no other staff
responded. At the end of the hall a CNA (staff J) was positioned inside the door that led to the outside dumpster area.
This door was not locked. The CNA reported, the facility just started putting someone to watch the doors sometime last
week.
During interview with a Licensed Practical Nurse (staff H) on [DATE] at 11:23 pm, she reported, the procedure prior to the
incident last week was for the oncoming nurse to eyeball the outside area to look for residents before coming up to the
unit. She stated, now we take a more aggressive approach. Now both shift nurses go outside together to check for residents.
This has changed after the incident last week, now we are very aggressive in checking the location of our residents.
During interview with a Registered Nurse supervisor (staff K) on [DATE] at 11:35 pm, he reported, there is a code to get
through the doors on the 1st floor West and East Wing. If you enter the code an alarm will sound. There is a CNA posted at
each door ,[DATE]. This started last week. Prior to posting a CNA at each exit door on the 1st floor, we had a security
guard that made rounds. They walk the first floor every 30 minutes to an hour. Prior to having the CNA's monitor the doors,
the security guard would respond if the East/West exit door alarms sounded. The supervisor also makes rounds including the
1st floor. There is also a secretary at the front desk until 9:00 pm. After 9:00 pm, the supervisor and/or the security
guard makes rounds on this floor. The security guard can hear the alarms from outside. I do not think the 1st floor alarms
can be heard upstairs. We also have a CNA scheduled to work in the smoking area on each shift. The CNA can not leave the
residents unattended, so they can call the supervisor if they hear the alarm, but they can not leave the smoking area.
During interview with the Director of Nursing (DON) on [DATE] at 12:13 am, she reported, the facility does not have any
video coverage anywhere in the building. The nurses do not have the ability to view the first floor from the units.
Observation on [DATE] at 12:25 am at the first floor West Wing exit door, the surveyor attempted to exit the door resulting
in the alarm sounding. The CNA did not respond and was not visible at the exit door. The Chief Executive Officer (CEO),
Nursing Home Administrator (NHA) and the DON responded when the door was opened after the 15 second delay. The CNA
appeared
from the stairwell after the administrative staff arrived at the exit door. The CEO stated, the CNA was behind the door,
but it was obseved, the CNA did not appear when the alarm sounded.
On ,[DATE] at 12:30 am at the first floor East Wing exit door, the surveyors attempted to exit the double doors leading down
the hall near the kitchen to the East wing exit door. The alarm sounded and the door opened following a 15 second delay.
The CEO was present. The CNA was down the hall at the exit door, but did not respond to the alarm. The CEO stated, her job
was to monitor the exit door at the end of the hall, not the alarm.
Observation on [DATE] at 8:55 am upon arrival to the facility revealed, a CNA outside in the smoking area in clear view of
the front door and the smoking area. During interview with a CNA (staff L), she said she is a CNA, but is a per diem
security guard as well. Review of the security schedule confirms this employee is on the schedule to work daytime security.
There were staff members visible monitoring the exit door at the East and West wing exits on the 1st floor.
During interview with a representative from the Dade County Guardianship Program on [DATE] at 11:50 am, the guardian for
resident #1 reported, he had been assigned to this case for about 2 months. He said, he was contacted on [DATE] in the
morning about 10:00 am by the Director of Nursing. The guardian reported, I was told he went missing about 3:00 am. She
told me, he was seen about 3:30 in the morning walking around the building. She told me that he was returned to his room.
When I spoke to them, I can not recall what time they said they started to search for him. The next call I received was on
[DATE] to inform me that the ward was found deceased next to a canal. Prior to coming to the nursing home he was at the
hospital and prior to this he was at an ALF. He was sent out of the ALF due to the same situation. I was at the ALF on
[DATE]th and the nurse informed me that the ward jumped the fence the day before ([DATE]) and was found on a busy
intersection near the highway. On [DATE], the facility (ALF) called me and informed me that he was Baker Acted (The Florida
Mental Health Act allows the involuntary and voluntary instituitionalization and examination of an individual) to the
hospital for self -endangerment because he tried to elope again. He was sent to the hospital and I was informed he could
OMB NO. 0938-0391
CORRECTION NUMBER
105469
MIAMI, FL 33179
not return because of the safety concern that he was trying to escape form the facility. I did not see the ward at the
Level of harm - Immediate nursing home as he was only there about a week. I planned to visit him that week. I had not spoken to anyone at the
jeopardy facility until I received the phone call.
During interview conducted via telephone by a Creole speaking surveyor with the security guard (staff M) on [DATE] at 10:00
Residents Affected - Few am, he revealed that he works at the facility on Tuesday, 7:00 pm-7:00 am, Friday, 7:00 pm-7:00 am and Sunday 7:00 am -
3:00 pm. He works as a security guard, to make sure that the residents do not go out the building. He is responsible to
watch the front gate only, watch the cars that are going in and out and also make sure that the residents do not leave the
facility. Before the incident, no one was responsible to watch the back door. They implemented that after the incident. He
revealed, people can exit the building through the back door. There is an alarm in the middle door that is coded, sometimes
if you do not make sure that the door is closed completely it may stay open. The door that is outside by the garbage does
not have any code. The front door does not have a code it is an automatic door. There was no security guard in the back,
only the front. The guard reported, he does not make rounds, he stays in the front only, and that is his responsibility.
When he came to work at 7:00 pm on Tuesday [DATE], the nurse asked him if he saw the resident, he described the resident to
him, he does not remember the name of the nurse, he clocked in, and he came to his post. After a few minutes around 7:30
pm, they told him again, that they have been looking everywhere for him on the other floors and they wanted to look for him
in the parking lot, on all the floors, all the bathrooms. They continued to look for him for the whole night. He left on
Wednesday morning, they had not found him.
During interview with the DON on [DATE] at 1:00 pm, she reported, at 10:46 pm on [DATE] resident (#1) was noted not to be in
his room or on the grounds at the time of rounds by the CNA and the nurse. All the units were notified and the staff
conducted a thorough search of the facilities grounds and a ,[DATE] mile radius outside of the facility. After that part of
the search, law enforcement officers were contacted (time unknown). I was initially called at 10:46 pm and again about an
hour later. At that time, they had called law enforcement. A report was taken by the officer. The resident's physician was
present in the facility. A call was made to Dade County Guardianship Program and a message was left for his guardian. All
other residents were accounted for except resident #1. The security guards and nursing staff continued the search.
Surrounding hospitals were called. On [DATE] at 7:00 am on report, the nursing supervisor reported, the resident had still
not returned to the facility. Law enforcement was called and they had no update. All staff who had worked with the resident
was interviewed. An attempt was made to interview his roommate, but due to his cognitive status he could not be
interviewed. On [DATE] around 3:00 pm, an employee from the ALF next door called and reported that a body was in the lake.
This is the lake on the property at the East end of this building. At the time of notification 911 was called. They
responded immediately and proceeded with the investigation. At about 10:30 pm, they called for an employee of the facility
to identify the body. The compliance officer identified the body of resident #1. At approximately 10:40 pm, the NHA placed
a call to the Dade County Guardian and a message was left. The guardian responded with a call on ,[DATE] at 10:30 am and
the DCF investigator entered the facility to investigate. DCF was called on [DATE] in the evening by the Social Service
Consultant. I spoke to the guardian during the investigation on the morning of [DATE]. Any additional contact with the
guardian was made by the administrator.
The DON stated, at the time of the incident, the facility had one monitor from maintenance who is responsible to monitor the
back section of the facility. This is a 12 hours shift and they make routine rounds (not scheduled) of the outside area on
the East and West side of the building to check for residents and/or anyone on the property. This is a non-resident area,
but there were some kids previously observed on the grounds so the area is monitored. The security guard is responsible for
the front door and the entrance and exit gate in the parking lot. The C N A monitors the smoking area. There are alarms on
the exit doors on each floor. The person making rounds monitors the alarms. All of the gates are locked outside these
doors. If the alarm on either one of these doors sounds, the maintenance person scheduled that shift is responsible for
checking if the alarm sounds. Since this incident, I have placed a staff member to monitor the East and West exit door 24
hours a day. We had good staffing and had already started a project to replace the fence with a higher fence. This started
on [DATE] and was part of our remodeling plan. Another change that was made was to have the receptionist work 3:00pm-11:30
pm. They used to leave at 8:30 pm.
During interview with the Receptionist (staff P) on [DATE] at 2:12 pm, she said she works in the lobby area as the
Receptionist. My shift is 3:30 to 8:30 pm. I do not have anyone relieve me after 8:30 pm. I recall this resident (#1) came
down on my shift one time and he was taken back upstairs. I want to say this was close to when I was leaving. I did not see
him again before I left. He was not downstairs very long. We do not let him stay downstairs very long, not for any
particular reason, but we do not like residents lingering in the lobby for too long. I am not sure if he is allowed to go
outside, but when he would come down and walk around without any sense of direction we would send him right back upstairs.
When I work as the receptionist anybody who is present on the floor can answer an alarm. I do not recall anyone setting off
the alarms on the night of [DATE]. The security guard and the smoking monitor stay outside. This resident moved very slowly
and there were times he would come down to the lobby and just look around. I would send him back upstairs.
During interview with a Licensed Practical Nurse (staff Q) on [DATE] at 2:45 pm, he reported, he remembers completing the
Elopement Risk Assessment for resident #1. He stated, this information would either come from the papers sent from the
hospital or from a verbal report. The hospital will call to give verbal report about the patient. Staff Q reported, I can
not recall specifically if they told me that this patient had a history of [REDACTED]. The protocol is, if a resident
scores higher than 10 on the assessment they are an elopement risk, so they are placed on one on one supervision for 72
hours and then the doctor is called to determine if the one to one should continue. In this case the one to one was
discontinued.
During interview with a Licensed Practical Nurse (staff N) via telephone on [DATE] at 3:01 pm, she verified she was the
nurse working on the 3rd floor west wing during the ,[DATE] shift on [DATE]. She verified, she was the nurse responsible
for resident #1. Staff N reported, he ambulated a lot and he frequently went down to the lobby area. I had not seen him
outside, but I understand he did go outside. He was alert and oriented to his name, but I am not sure he was oriented to
his surroundings. He would respond to commands. Supervision required included, the routine, he did not require one to one
at that time. He was compliant, not combative and I am not aware of any times he tried to leave the building. On [DATE]
during rounds about 3:30 pm, he was ambulating around the floor. He was on the floor from 3:30 up until just after 7:00 pm
or maybe around 8:00 pm. I went down the hallway to do medication pass and around 9:00 pm the C N A told me she could not
locate him. He was not in his room. I told her to check the lobby and he was not down there. By now, it was 9:30 or closer
to 10:00 pm. We checked the 3rd floor and then the whole building and he was not found. We searched the grounds. During
this time we notified the supervisor and called the DON and the police. We continued the search even after the police were
notified. We checked the surrounding neighborhood by car and he was not located. The doors on the 1st floor are monitored
by a CNA and there is a security guard. I can not tell you exactly when they started to place a CNA at each door. There
were no CNAs monitoring the doors on that particular night. If a resident is not on a specified monitoring schedule, all
residents are checked every 2 hours. If a resident is at risk for falls, they are checked more often. A resident determined
to be at risk for elopement we try to keep them in the dining room or in an area where they can be monitored. This resident
was not at risk for elopement at the time. He was on one to one upon admission for a couple of days, but that was withdrawn
because he did not show any signs. The protocol is to d/c (discontinue) the one to one if no sign is shown within 72 hours.
We call the doctor and get an order to d/c the one to one.
During interview with a Certified Nursing Assistant (staff G) via telephone on [DATE] at 3:20 pm, she verified that she was
assigned to care for resident #1 on [DATE]. She said, last week when I came in at 3:00 o'clock I saw this resident in the
dining room watching television with other residents. Then I saw him about 4:30 pm when I provided incontinence care. I had
to change him every one to two hours. I saw him about 4, 5:30 and at ,[DATE]:30 pm. I saw him every time except at 9:30 pm.
When I made rounds at 9:30, I did not see him in the room. The nurse told me to go downstairs to look for him and I did not
find him. This was the first time I took care of him. He walked around, he walked very slowly. I do not know if he goes
downstairs, I do not care for him before. He was busy during my shift. I have to check him every ,[DATE] hours because he
is incontinent. I do not know if he goes outside.
Review of a job description (undated) provided by the facility (no position listed) indicates responsibilities include, but
are not limited to: Patrol interior and exterior of the building, provide rapid and appropriate assistance to residents and
staff, access control of all common areas, inform supervisor of any incidents that occur throughout the shift, enforcement
of employee parking, emergency response to firm alarms and disturbances on the property, redirection of residents as
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MIAMI, FL 33179
needed, and provide residents escorts as needed. The DON who provided the job description was asked, what position this job
Level of harm - Immediate description covered? She stated, security. She then provided an additional copy on [DATE] 1:35 pm, which included the title
jeopardy (Monitor and Security Personnel). This copy was dated [DATE], revised [DATE].
During interview with a security guard (staff O) via telephone on [DATE] at 11:58 am, he confirmed, he works security taking
Residents Affected - Few care of the residents and they do not go inside. He said, he only watches the two front doors of the nursing home and the
parking lot, but nothing else. He said, he has nothing to do with the inside of the nursing home and does not watch any
other door. He said, no one has left the facility during his shift. He said, that no one had told him that they were
looking for a resident and he did not observe anyone looking for a resident either.
During interview with the Medical Director and Primary Care Physician (PCP) for resident #1 via telephone on [DATE] at 10:34
am, she said the day resident #1 went missing, I happened to be in the building for a planned visit. I was informed that he
was missing. I cannot recall what time I was called, but I was on my way to the building. I am not able to say what time,
but it is just beginning to get dark. We discussed the search plan to find the resident. The search was already started. We
discussed ways to be more vigilant in monitoring this patient. After the event we had a QA (Quality Assurance) meeting via
telephone to discuss what needed to be done to prevent a reoccurrence of such an event. Changes that were made included,
beefing up the security on the first floor, staff were in-serviced regarding implementing increased security, they put up
camera's at the exit doors on the main floor and they have security stationed on both exit doors on the first floor. There
were some recent discussions of supervision and revision of the elopement policy and procedures. The PCP said, she was very
surprised that this happened. He had shown improvement after admission. He was very quiet. He walked slowly with a
shuffling gait. After three days on one to one, the facility reported that the resident did not show any signs of risk,
therefore I discontinued the one to one supervision. According to the notes from prior placements, I was aware that he had
a history of [REDACTED]. This patient was safe and not threatening, so the one to one was not indicated after 72 hours,
from the reports I got from the facility. The facility also has security available to monitor the patients. I am not sure
exactly what their(TRUNCATED)
F 0323 Make sure that the nursing home area is free from accident hazards and risks and provides
supervision to prevent avoidable accidents
Level of harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
jeopardy Based on observation, record review and interview, the facility failed to provided adequate supervision in a safe and secure
environment to prevent one (resident #1) of 14 sampled residents from eloping from the facility. The facility identified 3
Residents Affected - Few current residents at risk for elopements and three of the 14 sampled residents were at risk for elopements. These failures
potentially resulted in the death of resident #1. Resident #1 was cognitively impaired and had a history of [REDACTED]. The
facility's elopement assessment indicated that he was a high risk for elopement. The facility identified 3 current
residents at risk for elopements and three of the 14 sampled residents were at risk for elopements. The failure to provide
adequate supervision and ensure a safe and secure environment resulted in the determination of immediate jeopardy to the
health and safety of the residents. There were 175 residents residing in the facility. The immediate jeopardy was removed
on [DATE].
The scope and severity for F323 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is
not immediate jeopardy as of [DATE]. The scope and severity was lowered as a result of the facility's corrective actions
implemented as of [DATE]. These corrective actions were verified by the survey team through observation, record review and
interview.
Cross Reference to F224 and F490.
Findings included:
Record review revealed a Federal Immediate Report submitted to AHCA (Agency for Health Care Administration. The report
indicated the type of incident was neglect. The description of the incident included: 10:46 pm on [DATE] resident (#1) was
noted not in room or on common grounds at time of rounds. All units were notified and staff immediately conducted a
thorough search of the facility grounds, property, and searched a one to two mile radius. After the search, law enforcement
was contacted, they visited the facility and a report was completed. The resident's physician was present in the facility,
Administrator and Director of Nursing. A message was left for local County Guardianship. The report indicated the State
Abuse Registry was notified on [DATE]. Review of the Federal Five Day Report submitted to AHCA indicated the facility was
informed on [DATE] at 3:00 pm by an employee from an ALF (Assisted Living Facility) that there is a body observed in the
lake behind the ALF. Immediately upon notification the facility contacted 911 and Fire Rescue. The Police proceeded to
initiate their investigation. At approximately at 10:30 pm on [DATE], the body was identified as resident (#1). The
facility's corrective action included, adding additional staff above the required ratio, staff have been added across all
three shifts. Additional staff have been added to ensure no additional residents leave without facility or physician
approval. All staff have been re-in serviced on abuse, supervision and elopement policies. The Nurse and C.N.A. (certified
nursing assistant) assigned to resident on the ,[DATE] shift on [DATE], were suspended pending a risk management and
administrative determination.
Record review revealed an Investigative Summary submitted by the Department of Children and Families (DCF) which included
the following sequence of events: [DATE] at 9:26 pm Resident (#1) is a vulnerable adult due to the fact that he has an
unspecified cognitive impairment, cardiac arterial disease, anemia, insomnia, hypertension, and a chronic medical
condition. On [DATE], he was discovered missing from the 3rd floor where he was last seen around 11:00 pm. He was under
regular monitoring, which means that he is checked on by staff every two hours. The facility is not a locked facility. It
is unknown how he was able to get by security and a gate in the front of the facility. He has a legal guardian. On [DATE]
at 10:04 pm Resident (#1) is a vulnerable adult who suffers from cardiac problems, hypertension, cognitive impairments,
depression and a chronic medical condition. Due to his cognitive impairment he is very forgetful and easily confused. There
is a concern for resident (#1) because unbeknownst to staff he went missing on [DATE]. The staff does not know what time he
left the facility, but he was noted missing around 11 pm. Although the facility is not a locked down facility, after hours
the only doors that are unlocked are the front doors. There was a security guard on duty from 7 pm until 7 am on the day he
went missing. A missing person's report was filed with law enforcement at 11:30 pm on [DATE], but his whereabouts were
still unknown. On [DATE], Resident (#1) was a vulnerable adult due to Organic Brai[DIAGNOSES REDACTED] with a history of
Dementia and Paranoia. He was discovered missing from the facility at 3:00 am on [DATE]. He left the facility unattended
and as a result he was found drowned on [DATE]. The facility was unable to explain how he was able to get out of the
facility. He was found in a lake near the facility. In order to leave the facility you must be buzzed out to leave by
staff. He had no history of leaving the facility.
During interview via telephone with the DCF investigator on [DATE] at 1:58 pm, it was reported, the final DCF report was not
completed as final interviews must be conducted. The investigator reported, The facility told me the resident was seen
around 10:30pm or so. Shift change is at 11:00 pm. During the 11:00 pm rounds he was not present when the staff was trying
to account for all the residents. A search was started immediately in the facility, the grounds, and the neighborhood. The
police were called during the time of the search. He was not found until the following day. The staff said the facility is
locked at that time of night. There is a security guard at the front door and the gate should be locked.
Observation on [DATE] at 8:00 pm upon entrance to the parking area revealed, a closed gate which opened via electronic
activation when the car approached the gate. There was also a gate to exit the parking area which was closed. When the
gates were approached on foot from inside, they would not open. A security guard was posted next to the front door outside
the facility. There were approximately 12 residents sitting outside in the smoking area. There was a fence at the end of
the smoking area which was secured with chains and a combination locks. There was also a fence surrounding a lake on the
East end of the building. There was an area at the end of the fence where the gate was damaged and had been secured with a
second piece of fencing. This area was not visible where the security guard was positioned. This area could be accessed
near the dumpster area and is not accessible from the front area of the building or through the front door. The only way to
access this portion of the grounds is through the East Wing exit door.
Observation on the first floor on [DATE] at 8:20 pm revealed, a Certified Nursing Assistant (CNA) at the West Wing exit
door. This door was locked and required a code to exit the building. The door also had a sign that read push until alarm
sounds - door can be opened in 15 seconds. The door at the opposite side of the building (East Wing) in the hall that leads
OMB NO. 0938-0391
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to the kitchen and laundry area had had an alarmed double door with a key pad. A sign on this door read push until alarm
Level of harm - Immediate sounds - door can be opened in 15 seconds. The handle of the door was pushed, the alarm sounded. After 15 seconds, the
jeopardy surveyors passed through the door. There was no staff that responded to the alarm. At the end of the hallway, the door to
the outside was unlocked and there was a C N A positioned at the door.
Residents Affected - Few During interview with a Licensed Practical Nurse (staff I) on [DATE] at 9:00 pm, she reported, report is done with my relief
between 11:00 pm and 11:15 pm. Walking rounds are done with the oncoming shift. Staff I stated, last Tuesday ([DATE]) the
staff came up to this floor looking for resident (#1). We searched every room on this floor including the resident rooms,
bathrooms, and the dining area. I do not remember exactly what time this happened, but I remember that I was passing my
9:00 pm medications so it was between 8:30 and 9 pm. After I finished my medications, I went downstairs to see if he was
found and they said no.
During interview with a Licensed Practical Nurse (staff C) on [DATE] at 9:17 pm, she reported, she works different shifts,
but her primary shift is the ,[DATE]pm shift. The procedure when I arrive is to do a walk through to check every room to
check to make sure everyone is alive and well and in good condition. At the end of the shift the same thing is done with
the oncoming nurse. I also have to make rounds at least every 2 hours. The C N A's also do walking rounds at the beginning
and end of each shift. They are responsible to visibly see each patient. If not, they report to the nurse. One day last
week, we could not find a patient. I was the ,[DATE] supervisor that night. I was making rounds on the 3rd floor. I saw the
patient about 9:30 pm - 10:00 pm. He was at the nurse's station downstairs on the 3rd floor, and then at one point he was
walking to his room. Since he was going towards his room, I left the floor to make rounds on another floor. I went back to
the 3rd floor at about 10:,[DATE]:45 pm. I made rounds on the unit and the CNA's were making their last rounds. He was not
in his room at that time. He was a very tall 6 foot man. We started to search the floor. We searched the entire floor room
to room and could not find him. The 2nd and 4th floors were also searched. We checked the outside smoking area and asked
everybody that was downstairs. We spoke to other residents and the security guard and nobody saw him. After searching the
grounds, I circled the block in my car. I called the DON and she said he has to be on the grounds, look around some more.
After searching the grounds again, I called the DON back and she instructed me to call the police (11:30pm - 12:00am). The
police arrived and implemented a search. This gentleman was alert, but confused. He was ambulatory, but walked very slowly.
He was a tall elegant man. He would spend a fair amount of time outside in the smoking area and walking about the grounds.
He liked to talk to people. There are three exits downstairs, the front door and two side doors. The side doors have
alarms. Just the front door can be accessed in and out. The exit door by the kitchen requires a code to get out. The other
door at the end of the hall is locked at a certain time. It also has a code. The main door is the front door. Security is
here around the clock. The gate is also locked at night and you have to have a vehicle to get out. He could not have gotten
out through the gate. I checked the local hospitals and looked everywhere. He was found right outside the facility. I was
not here when he was found. Nobody has any idea how he got out the entire area is secured.
During interview with a Licensed Practical Nurse (staff F) on [DATE] at 9:52 pm, she reported, she was working on this floor
(3rd) on the East side last Tuesday on the ,[DATE] shift. What I recall is that the nurse was doing her last medication
pass around 9:00 O ' clock. (West Wing). Before she got to the resident (#1) with medication, the CNA told the nurse she
could not find this resident. He was not in his room (#323 M). We checked each room on the 3rd floor and called the
supervisor. All the rooms in the building were searched. The grounds outside were searched, but it is dark outside. We also
were sent out in our cars to look for the resident. It is pitch black outside, I am not sure if there are any lights
outside, but it is very dark. He was alert with some mild confusion, but was easy to redirect. He would follow direction
for short periods of time. He was allowed to go outside by himself. At times he would go outside and then come back. I am
not aware that he had a history of [REDACTED]. We checked the back parking lot by the dietary end. The gates in the front
are locked at all times, but we went out looking anyway. There is a fence by the smoking area that is also locked at all
times. We also have a double pad lock on the door at the end of the hall by the kitchen. There is a double door that
requires a key pad to get through. The door at the end of the hall has no lock. It is supposed to be secured at the first
set of double doors. There are alarms at the end of the hallway for each door on the floors, but the double doors
downstairs are not alarmed. You can not open the door without knowing the code. They now have staff at every door. This
started the same day. There is now a CNA at the two exit doors in the hall. This is a new protocol that started after the
incident. We have security ,[DATE]. They patrol the whole front area and the parking lot. This resident was not found until
the next day.
Observation on the 1st floor East Wing on [DATE] at 10:15 pm revealed, the double doors that led to the hallway to the
kitchen and laundry area. The sign on the door read, push until alarm sounds - door can be opened in 15 seconds. There was
also a key pad to open the door. Surveyors engaged/pushed on the door, the alarm sounded for 15 seconds and then the door
was opened. There was no staff observed responding to the alarm. The maintenance director was close by, but no other staff
responded. At the end of the hall a CNA (staff J) was positioned inside the door that led to the outside dumpster area.
This door was not locked. The CNA reported, the facility just started putting someone to watch the doors sometime last
week.
During interview with a Licensed Practical Nurse (staff H) on [DATE] at 11:23 pm, she reported, the procedure prior to the
incident last week was for the oncoming nurse to eyeball the outside area to look for residents before coming up to the
unit. She stated, now we take a more aggressive approach. Now both shift nurses go outside together to check for residents.
This has changed after the incident last week, now we are very aggressive in checking the location of our residents.
During interview with a Registered Nurse supervisor (staff K) on [DATE] at 11:35 pm, he reported, there is a code to get
through the doors on the 1st floor West and East Wing. If you enter the code an alarm will sound. There is a CNA posted at
each door ,[DATE]. This started last week. Prior to posting a CNA at each exit door on the 1st floor, we had a security
guard that made rounds. They walk the first floor every 30 minutes to an hour. Prior to having the CNA's monitor the doors,
the security guard would respond if the East/West exit door alarms sounded. The supervisor also makes rounds including the
1st floor. There is also a secretary at the front desk until 9:00 pm. After 9:00 pm, the supervisor and/or the security
guard makes rounds on this floor. The security guard can hear the alarms from outside. I do not think the 1st floor alarms
can be heard upstairs. We also have a CNA scheduled to work in the smoking area on each shift. The CNA can not leave the
residents unattended, so they can call the supervisor if they hear the alarm, but they can not leave the smoking area.
During interview with the Director of Nursing (DON) on [DATE] at 12:13 am, she reported, the facility does not have any
video coverage anywhere in the building. The nurses do not have the ability to view the first floor from the units.
Observation on [DATE] at 12:25 am at the first floor West Wing exit door, the surveyor attempted to exit the door resulting
in the alarm sounding. The CNA did not respond and was not visible at the exit door. The Chief Executive Officer (CEO),
Nursing Home Administrator (NHA) and the DON responded when the door was opened after the 15 second delay. The CNA
appeared
from the stairwell after the administrative staff arrived at the exit door. The CEO stated, the CNA was behind the door,
but it was obseved, the CNA did not appear when the alarm sounded.
On ,[DATE] at 12:30 am at the first floor East Wing exit door, the surveyors attempted to exit the double doors leading down
the hall near the kitchen to the East wing exit door. The alarm sounded and the door opened following a 15 second delay.
The CEO was present. The CNA was down the hall at the exit door, but did not respond to the alarm. The CEO stated, her job
was to monitor the exit door at the end of the hall, not the alarm.
Observation on [DATE] at 8:55 am upon arrival to the facility revealed, a CNA outside in the smoking area in clear view of
the front door and the smoking area. During interview with a CNA (staff L), she said she is a CNA, but is a per diem
security guard as well. Review of the security schedule confirms this employee is on the schedule to work daytime security.
There were staff members visible monitoring the exit door at the East and West wing exits on the 1st floor.
During interview with a representative from the Dade County Guardianship Program on [DATE] at 11:50 am, the guardian for
resident #1 reported, he had been assigned to this case for about 2 months. He said, he was contacted on [DATE] in the
morning about 10:00 am by the Director of Nursing. The guardian reported, I was told he went missing about 3:00 am. She
told me, he was seen about 3:30 in the morning walking around the building. She told me that he was returned to his room.
When I spoke to them, I can not recall what time they said they started to search for him. The next call I received was on
[DATE] to inform me that the ward was found deceased next to a canal. Prior to coming to the nursing home he was at the
hospital and prior to this he was at an ALF. He was sent out of the ALF due to the same situation. I was at the ALF on
[DATE]th and the nurse informed me that the ward jumped the fence the day before ([DATE]) and was found on a busy
intersection near the highway. On [DATE], the facility (ALF) called me and informed me that he was Baker Acted (The Florida
OMB NO. 0938-0391
CORRECTION NUMBER
105469
MIAMI, FL 33179
Mental Health Act allows the involuntary and voluntary instituitionalization and examination of an individual) to the
Level of harm - Immediate hospital for self -endangerment because he tried to elope again. He was sent to the hospital and I was informed he could
jeopardy not return because of the safety concern that he was trying to escape form the facility. I did not see the ward at the
nursing home as he was only there about a week. I planned to visit him that week. I had not spoken to anyone at the
Residents Affected - Few facility until I received the phone call.
During interview conducted via telephone by a Creole speaking surveyor with the security guard (staff M) on [DATE] at 10:00
am, he revealed that he works at the facility on Tuesday, 7:00 pm-7:00 am, Friday, 7:00 pm-7:00 am and Sunday 7:00 am -
3:00 pm. He works as a security guard, to make sure that the residents do not go out the building. He is responsible to
watch the front gate only, watch the cars that are going in and out and also make sure that the residents do not leave the
facility. Before the incident, no one was responsible to watch the back door. They implemented that after the incident. He
revealed, people can exit the building through the back door. There is an alarm in the middle door that is coded, sometimes
if you do not make sure that the door is closed completely it may stay open. The door that is outside by the garbage does
not have any code. The front door does not have a code it is an automatic door. There was no security guard in the back,
only the front. The guard reported, he does not make rounds, he stays in the front only, and that is his responsibility.
When he came to work at 7:00 pm on Tuesday [DATE], the nurse asked him if he saw the resident, he described the resident to
him, he does not remember the name of the nurse, he clocked in, and he came to his post. After a few minutes around 7:30
pm, they told him again, that they have been looking everywhere for him on the other floors and they wanted to look for him
in the parking lot, on all the floors, all the bathrooms. They continued to look for him for the whole night. He left on
Wednesday morning, they had not found him.
During interview with the DON on [DATE] at 1:00 pm, she reported, at 10:46 pm on [DATE] resident (#1) was noted not to be in
his room or on the grounds at the time of rounds by the CNA and the nurse. All the units were notified and the staff
conducted a thorough search of the facilities grounds and a ,[DATE] mile radius outside of the facility. After that part of
the search, law enforcement officers were contacted (time unknown). I was initially called at 10:46 pm and again about an
hour later. At that time, they had called law enforcement. A report was taken by the officer. The resident's physician was
present in the facility. A call was made to Dade County Guardianship Program and a message was left for his guardian. All
other residents were accounted for except resident #1. The security guards and nursing staff continued the search.
Surrounding hospitals were called. On [DATE] at 7:00 am on report, the nursing supervisor reported, the resident had still
not returned to the facility. Law enforcement was called and they had no update. All staff who had worked with the resident
was interviewed. An attempt was made to interview his roommate, but due to his cognitive status he could not be
interviewed. On [DATE] around 3:00 pm, an employee from the ALF next door called and reported that a body was in the lake.
This is the lake on the property at the East end of this building. At the time of notification 911 was called. They
responded immediately and proceeded with the investigation. At about 10:30 pm, they called for an employee of the facility
to identify the body. The compliance officer identified the body of resident #1. At approximately 10:40 pm, the NHA placed
a call to the Dade County Guardian and a message was left. The guardian responded with a call on ,[DATE] at 10:30 am and
the DCF investigator entered the facility to investigate. DCF was called on [DATE] in the evening by the Social Service
Consultant. I spoke to the guardian during the investigation on the morning of [DATE]. Any additional contact with the
guardian was made by the administrator.
The DON stated, at the time of the incident, the facility had one monitor from maintenance who is responsible to monitor the
back section of the facility. This is a 12 hours shift and they make routine rounds (not scheduled) of the outside area on
the East and West side of the building to check for residents and/or anyone on the property. This is a non-resident area,
but there were some kids previously observed on the grounds so the area is monitored. The security guard is responsible for
the front door and the entrance and exit gate in the parking lot. The C N A monitors the smoking area. There are alarms on
the exit doors on each floor. The person making rounds monitors the alarms. All of the gates are locked outside these
doors. If the alarm on either one of these doors sounds, the maintenance person scheduled that shift is responsible for
checking if the alarm sounds. Since this incident, I have placed a staff member to monitor the East and West exit door 24
hours a day. We had good staffing and had already started a project to replace the fence with a higher fence. This started
on [DATE] and was part of our remodeling plan. Another change that was made was to have the receptionist work 3:00pm-11:30
pm. They used to leave at 8:30 pm.
During interview with the Receptionist (staff P) on [DATE] at 2:12 pm, she said she works in the lobby area as the
Receptionist. My shift is 3:30 to 8:30 pm. I do not have anyone relieve me after 8:30 pm. I recall this resident (#1) came
down on my shift one time and he was taken back upstairs. I want to say this was close to when I was leaving. I did not see
him again before I left. He was not downstairs very long. We do not let him stay downstairs very long, not for any
particular reason, but we do not like residents lingering in the lobby for too long. I am not sure if he is allowed to go
outside, but when he would come down and walk around without any sense of direction we would send him right back upstairs.
When I work as the receptionist anybody who is present on the floor can answer an alarm. I do not recall anyone setting off
the alarms on the night of [DATE]. The security guard and the smoking monitor stay outside. This resident moved very slowly
and there were times he would come down to the lobby and just look around. I would send him back upstairs.
During interview with a Licensed Practical Nurse (staff Q) on [DATE] at 2:45 pm, he reported, he remembers completing the
Elopement Risk Assessment for resident #1. He stated, this information would either come from the papers sent from the
hospital or from a verbal report. The hospital will call to give verbal report about the patient. Staff Q reported, I can
not recall specifically if they told me that this patient had a history of [REDACTED]. The protocol is, if a resident
scores higher than 10 on the assessment they are an elopement risk, so they are placed on one on one supervision for 72
hours and then the doctor is called to determine if the one to one should continue. In this case the one to one was
discontinued.
During interview with a Licensed Practical Nurse (staff N) via telephone on [DATE] at 3:01 pm, she verified she was the
nurse working on the 3rd floor west wing during the ,[DATE] shift on [DATE]. She verified, she was the nurse responsible
for resident #1. Staff N reported, he ambulated a lot and he frequently went down to the lobby area. I had not seen him
outside, but I understand he did go outside. He was alert and oriented to his name, but I am not sure he was oriented to
his surroundings. He would respond to commands. Supervision required included, the routine, he did not require one to one
at that time. He was compliant, not combative and I am not aware of any times he tried to leave the building. On [DATE]
during rounds about 3:30 pm, he was ambulating around the floor. He was on the floor from 3:30 up until just after 7:00 pm
or maybe around 8:00 pm. I went down the hallway to do medication pass and around 9:00 pm the C N A told me she could not
locate him. He was not in his room. I told her to check the lobby and he was not down there. By now, it was 9:30 or closer
to 10:00 pm. We checked the 3rd floor and then the whole building and he was not found. We searched the grounds. During
this time we notified the supervisor and called the DON and the police. We continued the search even after the police were
notified. We checked the surrounding neighborhood by car and he was not located. The doors on the 1st floor are monitored
by a CNA and there is a security guard. I can not tell you exactly when they started to place a CNA at each door. There
were no CNAs monitoring the doors on that particular night. If a resident is not on a specified monitoring schedule, all
residents are checked every 2 hours. If a resident is at risk for falls, they are checked more often. A resident determined
to be at risk for elopement we try to keep them in the dining room or in an area where they can be monitored. This resident
was not at risk for elopement at the time. He was on one to one upon admission for a couple of days, but that was withdrawn
because he did not show any signs. The protocol is to d/c (discontinue) the one to one if no sign is shown within 72 hours.
We call the doctor and get an order to d/c the one to one.
During interview with a Certified Nursing Assistant (staff G) via telephone on [DATE] at 3:20 pm, she verified that she was
assigned to care for resident #1 on [DATE]. She said, last week when I came in at 3:00 o'clock I saw this resident in the
dining room watching television with other residents. Then I saw him about 4:30 pm when I provided incontinence care. I had
to change him every one to two hours. I saw him about 4, 5:30 and at ,[DATE]:30 pm. I saw him every time except at 9:30 pm.
When I made rounds at 9:30, I did not see him in the room. The nurse told me to go downstairs to look for him and I did not
find him. This was the first time I took care of him. He walked around, he walked very slowly. I do not know if he goes
downstairs, I do not care for him before. He was busy during my shift. I have to check him every ,[DATE] hours because he
is incontinent. I do not know if he goes outside.
Review of a job description (undated) provided by the facility (no position listed) indicates responsibilities include, but
are not limited to: Patrol interior and exterior of the building, provide rapid and appropriate assistance to residents and
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staff, access control of all common areas, inform supervisor of any incidents that occur throughout the shift, enforcement
Level of harm - Immediate of employee parking, emergency response to firm alarms and disturbances on the property, redirection of residents as
jeopardy needed, and provide residents escorts as needed. The DON who provided the job description was asked, what position this job
description covered? She stated, security. She then provided an additional copy on [DATE] 1:35 pm, which included the title
Residents Affected - Few (Monitor and Security Personnel). This copy was dated [DATE], revised [DATE].
During interview with a security guard (staff O) via telephone on [DATE] at 11:58 am, he confirmed, he works security taking
care of the residents and they do not go inside. He said, he only watches the two front doors of the nursing home and the
parking lot, but nothing else. He said, he has nothing to do with the inside of the nursing home and does not watch any
other door. He said, no one has left the facility during his shift. He said, that no one had told him that they were
looking for a resident and he did not observe anyone looking for a resident either.
During interview with the Medical Director and Primary Care Physician (PCP) for resident #1 via telephone on [DATE] at 10:34
am, she said the day resident #1 went missing, I happened to be in the building for a planned visit. I was informed that he
was missing. I cannot recall what time I was called, but I was on my way to the building. I am not able to say what time,
but it is just beginning to get dark. We discussed the search plan to find the resident. The search was already started. We
discussed ways to be more vigilant in monitoring this patient. After the event we had a QA (Quality Assurance) meeting via
telephone to discuss what needed to be done to prevent a reoccurrence of such an event. Changes that were made included,
beefing up the security on the first floor, staff were in-serviced regarding implementing increased security, they put up
camera's at the exit doors on the main floor and they have security stationed on both exit doors on the first floor. There
were some recent discussions of supervision and revision of the elopement policy and procedures. The PCP said, she was very
surprised that this happened. He had shown improvement after admission. He was very quiet. He walked slowly with a
shuffling gait. After three days on one to one, the facility reported that the resident did not show any signs of risk,
therefore I discontinued the one to one supervision. According to the notes from prior placements, I was aware that he had
a history of [REDACTED]. This patient was safe and not threatening, so the one to one was not indicated after 72 hours,
from the reports I got from the facility. The facility also has security available to monitor the patients. I am not sure
exactly what their responsibilities are. Resident #1 was ambulatory with a very slow shuffling gait. He did have some
Psychiatric issues. It was difficult to assess his cognitive status since he did not talk.
During interview with the Nursing Home Administrator (NHA) on [DATE] at 11:45 am, he reported, in regards to the incident
which occurred on [DATE], he was notified by the Director of Nursing on the morning of [DATE]. The NHA reported,
F 0353 Have enough nurses to care for every resident in a way that maximizes the resident's well
being.
Level of harm - Minimal **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
harm or potential for actual Based on observation, interview, and record review, the facility failed to have sufficient nursing staff as evidenced by a
harm failure to administer medications after the nursing department was instructed by the staffing coordinator to cover an
entire wing while the scheduled nurse was not available in the facility for one wing out of 6 wings observed.
Residents Affected - Few Finding include:
Observation of the fourth floor Nurse Staffing board on 12/09/2015 at 5:44 pm showed, the Nursing Supervisor and 2 Nurse's
names (staff U and staff V), and 6 Certified Nursing Assistants (CNA) for a census of 59 residents. During observation,
staff U was passing medications and Staff V was unable to be located.
Interview and observation on 12/09/2015 at 5:44 pm conducted with the Nurse Supervisor (staff B) revealed, Nurse V called in
sick and another staff person was coming in. The nurse from the 7:00 am-3:00 pm shift left the facility, and she will cover
the east unit. The Nursing Supervisor (staff B) was observed at the nursing station, and not at the medication cart.
Interview on 12/09/2015 at 7:00 pm with Nurse (staff W) revealed, she started medication administration a little after 6:00
pm. Staff W revealed, she is passing medications that were due at 5:00 pm.
Interview and Observation on 12/09/2015 at 7:05 pm with the Nursing Supervisor (staff B) revealed, she thought the nurse was
coming in late after finding out the nurse called in sick. Staff B revealed, she was on orientation for the Nurse
Supervisor position and stated that she was going to do the med pass (medication administration). Staff B was observed at
the nursing station and not at the medication cart at this time.
Interview on 12/11/2015 at 12:05 pm with staff B revealed, the assignments were done by the staffing coordinator. The
assignments came pre-made and then placed on the board. Staff B revealed, there was always adequate staff because we have
it planned. The staffing coordinator was aware of the residents' acuity, so that assignments can be made. Staff B revealed,
rounds were made and, for any reason, a resident calls or a call light is on, she would answer the call light and notify
the nurse. If the resident needed a CNA, then she would call the CNA. Staff B revealed, if the CNA and nurse was busy, then
she would take care of the resident. Staff B revealed, she is not in charge of when a nurse calls in sick, the nurse will
call the Staff Coordinator and then the staffing coordinator will take care of staffing. Staff B revealed, if a nurse calls
in, they are to call 4 hours before their shift. If you are really sick, you call a day ahead, but if an emergency happens,
then it happens. If the nurse calls in, within an adequate amount of time, then the Staffing Coordinator will provide a
nurse. Staff B revealed, she was in the dining room because she believes nurse W came on duty before 6:00 pm.
Interview on 12/11/2015 at 12:22pm with the Staffing Coordinator revealed, if a nurse calls in, then we would find someone
to replace the nurse. The Staffing coordinator revealed, the per diem or part time nurse is called and if they say they
can't come, then the nurse on the particular shift is asked if they can work the next shift. The nurses are to call 2 hours
before the shift. If a nurse does not call before 2 hours, then the call is directed to the Director of Nursing (DON). The
staffing coordinator revealed, if a nurse or CNA comes in late then another nurse or CNA is asked to come in to relieve the
staff person for that shift. The Nurse Manager can also be asked to stay on the floor. If a nurse calls in late, the
staffing coordinator revealed, he would call the supervisor or call the one working on that shift to see if they can stay
till the nurse comes in. The Staffing coordinator revealed, the nurses assigned to cover are to take the floor and do what
they are supposed to do while they are waiting for the nurse to come in. The staffing coordinator revealed, there was a
nurse that called in sick at 10:00 am. Then, someone was called to replace that nurse and that nurse agreed, but had a
doctor's appointment at 1:30 pm. The Nurse stated that she would come after the appointment. The staffing coordinator
revealed that the nurse did not call him, but texted that she was having a lot of pain and could not make it. The staffing
coordinator revealed, he then told the nursing supervisor to take the floor until he found someone. The staffing
coordinator revealed, he informed the nursing supervisor at 3:00 pm. The staffing coordinator revealed, he notified a
Nursing Supervisor (staff C) that someone called off and asked her to stay on the floor until Nurse W arrived, then a few
minutes later staff B called the Staffing coordinator and notified both supervisors to take over the wing until Nurse W
came in.
Record Review of the Medication Administration Records on 12/09/2015 for the Medication Cart on the 4 floor east wing showed
medications, Finger sticks, and insulin was not given at the 5:00 pm and 4:30 pm medication administration times, they were
given over an hour late.
Review of the facility's Employee handbook showed under the subheading Attendance and Punctuality .On those rare occasions
when employees cannot avoid being late or leaving early or are unable to report to work as scheduled, they must notify
their supervisor or other designated representative of the facility at least four hours before their scheduled starting
time .
Review of the facility's undated Policy and Procedures Manual, the following was documented, Staffing Policy, Our facility
provides adequate staffing to meet care and services for our resident population. Policy Interpretation and Implementation,
1.) our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met.
Licensed nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services.
2.) Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as
outlined on the resident's comprehensive care plan 4.) Inquires or concerns relative to our facility's staffing should be
directed to the Director of Nursing.
During the review of the staffing policy statement and the policy interpretation and implementation, it did not document
procedures to ensure that residents are assigned to a nurse and/or assigned to a nurse when the scheduled nurse is not
available, and the responsibilities of the nurse who is covering until the scheduled nurse arrives.
OMB NO. 0938-0391
CORRECTION NUMBER
105469
MIAMI, FL 33179
Review of a Nurse Schedule/Grid, without a title, showed on 12/09/2015, the Nurse supervisor (Staff B) assigned to the
Level of harm - Minimal 3-11pm shift and an LPN was the charge nurse on the fourth floor.
harm or potential for actual Review of the policy for Physician orders [REDACTED].
harm
Residents Affected - Few

F 0386 Make sure that doctors see a resident's plan of care at every visit and make notes about
progress and orders in writing.
harm or potential for actual Based on record review and staff interview, the facility failed to ensure documentation of physician visits were dated for
harm one (resident #1) of fourteen records reviewed as evidenced by failure to date the initial history and physical.
Findings included:
Residents Affected - Few Record review revealed resident #1 was admitted to the facility on [DATE]. A history and physical (undated) revealed, chief
complaint: Anxiety and Agitation. History: [AGE] year old male patient admitted to this facility from (name of hospital)
behavioral health unit for skilled nursing care. Medical history:[MEDICAL CONDITION](Human Immunodeficiency Virus)
Disease,
Anxiety, Depression, [MEDICAL CONDITION], and Hypertension. Social history - ALF (Assisted Living Facility) resident, poor
historian. General: Awake, alert in NAD, ambulatory with shuffling gait, uses a cane occasionally. Rehab Potential: Fair.
Patient informed of medical condition: No, unable to comprehend. The history and physical was signed by the physician, but
there was no date to indicate when the physical was conducted.
During interview with the Director of Nursing (DON) on 12/8/15 at 1:00 pm and review of the clinical record for resident #1,
she confirmed there was no date in the initial history and physical. She reported, the document was signed by his primary
care physician.
During interview with resident #1's primary care physician on 12/10/15 at 10:34 am revealed, she saw this resident on
11/25/15, when I completed his history and physical. I understand there was no date on the document which was an oversight
because sometimes you are just in a hurry.
F 0387 Make sure that doctors visit residents regularly, as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Level of harm - Minimal Based on interview and record review, the facility failed to ensure that physician visits were conducted at least every 60
harm or potential for actual days for one (resident #5) out of 3 residents sampled and identified as a high risk for elopement.
harm Findings included:
Interview on 12/10/2015 at 3:24 pm with the physician revealed, the last time the residents were visited was in November
Residents Affected - Few 2015. The physician revealed, in November 2015 she saw everyone. The physician revealed, some residents were seen, but not
everyone for the month of December 2015. The physician stated, she was not sure about the last time she visited resident
#5. The physician revealed, sometimes she will put a note in the chart, but has an electronic medical record and then the
information is sent to the facility on ce completed.
Review of Resident #5's computer printed physician monthly progress notes dated 10/26/2015, 09/22/2015, 08/20/2015,
07/22/2015, and 06/15/2015 showed, notes were validated by an Advance Registered Nurse Practitioner (ARNP) and dated. The
medical record did not have a physician progress notes [REDACTED].
Review of the policy for Physician Visits dated 04/03/06 showed, The residents must be seen by a physician at least once
every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. A Physician visit is
considered timely if it occurs not later than 10 days after the date of visit.
F 0425 Safely provide drugs and other similar products available, which are needed every day and
in emergencies, by a licensed pharmacist
harm or potential for actual Based on observation, interview, and record review, the facility failed to administer medications after the nursing
harm department was instructed by the staffing coordinator to cover an entire wing while the scheduled nurse was not available
in the facility for one wing out of 6 wings observed. There was a delay in administering resident medications on the fourth
Residents Affected - Few floor unit.
Finding include:
Observation of the fourth floor Nurse Staffing board on 12/09/2015 at 5:44 pm showed, the Nursing Supervisor and 2 Nurse's
names (staff U and staff V), and 6 Certified Nursing Assistants (CNA) for a census of 59 residents. During observation,
staff U was passing medications and Staff V was unable to be located.
Interview and observation on 12/09/2015 at 5:44 pm conducted with the Nurse Supervisor (staff B) revealed, Nurse V called in
sick and another staff person was coming in. The nurse from the 7:00 am-3:00 pm shift left the facility, and she will cover
the east unit. The Nursing Supervisor (staff B) was observed at the nursing station, and not at the medication cart.
Interview on 12/09/2015 at 7:00 pm with Nurse (staff W) revealed, she started medication administration a little after 6:00
pm. Staff W revealed, she is passing medications that were due at 5:00 pm.
Interview and Observation on 12/09/2015 at 7:05 pm with the Nursing Supervisor (staff B) revealed, she thought the nurse was
coming in late after finding out the nurse called in sick. Staff B revealed, she was on orientation for the Nurse
Supervisor position and stated that she was going to do the med pass (medication administration). Staff B was observed at
the nursing station and not at the medication cart at this time.
Interview on 12/11/2015 at 12:05 pm with staff B revealed, the assignments were done by the staffing coordinator. The
assignments came pre-made and then placed on the board. Staff B revealed, there was always adequate staff because we have
it planned. The staffing coordinator was aware of the residents' acuity, so that assignments can be made. Staff B revealed,
rounds were made and, for any reason, a resident calls or a call light is on, she would answer the call light and notify
the nurse. If the resident needed a CNA, then she would call the CNA. Staff B revealed, if the CNA and nurse was busy, then
she would take care of the resident. Staff B revealed, she is not in charge of when a nurse calls in sick, the nurse will
call the Staff Coordinator and then the staffing coordinator will take care of staffing. Staff B revealed, if a nurse calls
in, they are to call 4 hours before their shift. If you are really sick, you call a day ahead, but if an emergency happens,
then it happens. If the nurse calls in, within an adequate amount of time, then the Staffing Coordinator will provide a
nurse. Staff B revealed, she was in the dining room because she believes nurse W came on duty before 6:00 pm.
Interview on 12/11/2015 at 12:22pm with the Staffing Coordinator revealed, if a nurse calls in, then we would find someone
to replace the nurse. The Staffing coordinator revealed, the per diem or part time nurse is called and if they say they
can't come, then the nurse on the particular shift is asked if they can work the next shift. The nurses are to call 2 hours
before the shift. If a nurse does not call before 2 hours, then the call is directed to the Director of Nursing (DON). The
staffing coordinator revealed, if a nurse or CNA comes in late then another nurse or CNA is asked to come in to relieve the
staff person for that shift. The Nurse Manager can also be asked to stay on the floor. If a nurse calls in late, the
staffing coordinator revealed, he would call the supervisor or call the one working on that shift to see if they can stay
till the nurse comes in. The Staffing coordinator revealed, the nurses assigned to cover are to take the floor and do what
they are supposed to do while they are waiting for the nurse to come in. The staffing coordinator revealed, there was a
nurse that called in sick at 10:00 am. Then, someone was called to replace that nurse and that nurse agreed, but had a
doctor's appointment at 1:30 pm. The Nurse stated that she would come after the appointment. The staffing coordinator
revealed that the nurse did not call him, but texted that she was having a lot of pain and could not make it. The staffing
coordinator revealed, he then told the nursing supervisor to take the floor until he found someone. The staffing
coordinator revealed, he informed the nursing supervisor at 3:00 pm. The staffing coordinator revealed, he notified a
Nursing Supervisor (staff C) that someone called off and asked her to stay on the floor until Nurse W arrived, then a few
minutes later staff B called the Staffing coordinator and notified both supervisors to take over the wing until Nurse W
came in.
Record Review of the Medication Administration Records on 12/09/2015 for the Medication Cart on the 4 floor east wing showed
OMB NO. 0938-0391
CORRECTION NUMBER
105469
MIAMI, FL 33179
medications, Finger sticks, and insulin was not given at the 5:00 pm and 4:30 pm medication administration times, they were
Level of harm - Minimal given over an hour late.
harm or potential for actual Review of the facility's Employee handbook showed under the subheading Attendance and Punctuality .On those rare occasions
harm when employees cannot avoid being late or leaving early or are unable to report to work as scheduled, they must notify
their supervisor or other designated representative of the facility at least four hours before their scheduled starting
Residents Affected - Few time .
Review of the facility's undated Policy and Procedures Manual, the following was documented, Staffing Policy, Our facility
provides adequate staffing to meet care and services for our resident population. Policy Interpretation and Implementation,
1.) our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met.
Licensed nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services.
2.) Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as
outlined on the resident's comprehensive care plan 4.) Inquires or concerns relative to our facility's staffing should be
directed to the Director of Nursing.
During the review of the staffing policy statement and the policy interpretation and implementation, it did not document
procedures to ensure that residents are assigned to a nurse and/or assigned to a nurse when the scheduled nurse is not
available, and the responsibilities of the nurse who is covering until the scheduled nurse arrives.
Review of a Nurse Schedule/Grid, without a title, showed on 12/09/2015, the Nurse supervisor (Staff B) assigned to the
3-11pm shift and an LPN was the charge nurse on the fourth floor.
Review of the policy for Physician orders [REDACTED].
F 0490 Be administered in an acceptable way that maintains the well-being of each resident .
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Level of harm - Immediate Based on observation, record review and interview, the facility failed to ensure effective administration to ensure the
jeopardy highest practical physical well-being of one (resident #1) of 14 sampled residents. Resident #1 eloped from the facility.
This failure potentially resulted in the death of resident #1 who was cognitively impaired. The administration failed to
Residents Affected - Few use resources effectively and efficiently to ensure resident #1, one of 3 residents who were at risk for elopement was free
from neglect and failed to provide adequate supervision in a safe and secure environment resulting in immediate jeopardy.
There were 175 residents residing in the facility. The immediate jeopardy was removed on 12/11/15.
The scope and severity for F490 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is
not immediate jeopardy as of 12/11/15. The scope and severity was lowered as a result of the facility's corrective actions
implemented as of 12/11/15. These corrective actions were verified by the survey team through observation, record review
and interview.
(Refer to F224 and F323)
Findings included:
During interview with the Nursing Home Administrator (NHA) on 12/10/15 at 11:38 am, he reported, he became the administrator
at this facility on 6/1/15. He reported, administratively, I am responsible to oversee the operation of the dietary,
maintenance, housekeeping, laundry, activities, and social service departments. I consult with the Director of Nursing
(DON) regarding oversight in the operation of the Nursing Department. Medical Services are overseen by the DON and I
consult with her regarding any issues related to medical services. I serve on the QA (Quality Assurance) committee and
attend the monthly meetings. I have some responsibility for oversight of contract review and renewal for any outside
services provided at the facility. I guess the Consultant Dietitian reports to me, the outside therapy department goes
through the DON.
Review of the facility's Organizational Chart revealed, the NHA is responsible for oversight for Medical Services and
Nursing Services as well as all other services provided. Review of the job description for the NHA signed on 6/1/2015
revealed, Purpose of your Job Description: The primary purpose of your job position is to direct the day to day functions
of the facility in accordance with current federal, state, and local standards, guideline, and regulations that govern
nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times.
Delegation of Authority: As Administrator, you are delegated the administrative authority, responsibility, and
accountability necessary for carrying out your assigned duties. Administrative responsibilities include, but are not
limited to: Plan, develop, organize, implement, evaluate, and direct programs and activities in accordance with guidelines
issued by the governing body, develop and maintain written policies and procedures and professional standards of practice
that govern the operation of the facility, make routine inspections of the facility to assure that established policies and
procedures are being implemented and followed, assume the administrative authority, responsibility, and accountability of
directing the activities and programs of the facility, ensure the facility is maintained in a clean and safe manner, and
assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct
identified quality deficiencies.
During interview with the NHA on 12/11/15 at 10:25 am, he revealed, he has been a licensed administrator since 1994. He
stated, he was not working as a NHA prior to accepting this position and the status of his license was active, but not
paid. He stated that he had not renewed/paid for the license renewal because he was working as an ALF (Assisted Living
Facility) administrator, not a NHA. He said, he paid for the renewal of his NHA license when he accepted this position.
When asked when he was last employed as a NHA he said he did remember exactly, but it was approximately 2001. Review of his
personnel record confirmed his last reported employment as a NHA was in 2001.
During interview with the NHA on 12/11/15 at 12:02 pm, he said to the best of his knowledge the personnel file provided was
complete and there were no additional documents. During interview and review of his personnel record, he confirmed his last
employment prior to this position (2001 to present) was self-employment owned my own company, not employed as a NHA and
from 2004 to 2006, I was employed as an Assistant Administrator at an ALF facility. From 2000 to 2001 I was employed as a
Nursing Home Administrator. He stated, his orientation to this facility included reviewing the policies and procedures for
the company. Otherwise, it was basically learning by rote. There was not really a formal orientation, but I have been
licensed for a long time. Basically, you throw your feet in the fire. I don't want to say that every building is the same,
but I have been licensed for a long time. In this particular case there was no additional orientation or time spent at any
of the other facilities owned by the company.
During interview with the Nursing Home Administrator (NHA) on 12/10/15 at 11:45 am, he reported, in regards to the incident
which occurred on 12/1/15, he was notified by the Director of Nursing on the morning of 12/2/15. The NHA reported, I was
not notified the night the incident occurred. I was notified upon my arrival to the building on 12/2/15 about 8:30 am. I
was informed we had a resident who eloped from the facility. The search was conducted according to our elopement policy. We
were continuing our search in the area at the time of my arrival. At this time I was shown the missing person report from
the police department, but the police were no longer at the facility. I was told that this resident was first discovered
missing at approximately 10:45 pm on 12/1/15. From what I understand, the DON saw this resident in her office on 12/1/15 at
8 pm. I feel that I was reasonably notified of the situation. Had I been called the night before, I would have asked the
same questions, have we implemented the elopement policy and have the police been called. The Abuse Hotline was called on
12/2/15 at approximately 9:00 pm. The resident body was found at approximately 3:00 pm on 12/2/15. The body was found by
the ALF staff. The ALF is located just due East of the facility. The body was found in the lake. The facility's elopement
policy is to search the grounds, notify the family and/or guardian, call the police to report a missing person, and notify
local emergency room s. The facility has added additional security measures which include placement of staff at both exit
doors (East and West wing exits) and continued security presence at the front door. The facility has three exits from the
1st floor which include the East and West exit doors and the front door. These positions have been implemented 24/7 in
response to this situation. Previous to this situation, we had a security staff stationed out front of the building as well
as a CNA who monitors the smoking area 24/7. The main security staff responsibilities included, monitoring the grounds,
including the entry and exit gates in the parking lot, watch for resident and visitors who come and go and interact as
needed. They are positioned up front - outside to monitor the front door and front area. Prior to this incident, the actual
security person would be anticipated to respond to alarms, but they cannot leave their post outside. If an alarm goes off
inside the building, they can check the exit doors outside the building, but they are not responsible to come inside to
respond to alarms by entering the building. The staff inside the building is responsible to respond to alarms. Up to 8:00
OMB NO. 0938-0391
CORRECTION NUMBER
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MIAMI, FL 33179
at night, dietary staff is present on the first floor and laundry services through the night. The Receptionist was here
Level of harm - Immediate until about 8:00 pm and now we have extended the hours until 11:00 pm. I do not know if the door alarms on the first floor
jeopardy can be heard upstairs on the units. I imagine the nursing supervisor will come down and make rounds from time to time on
the 1st floor. There is a head count done at the change of each shift. At this time, we do not have any conclusion as to
Residents Affected - Few how the resident got out of the building.
During observations, record reviews and interviews the following concerns were identified during the complaint survey
investigation:
The facility failed to ensure that they provided the services necessary to avoid physical harm which resulted in neglect.
The facility failed to ensure adequate supervision in a safe and secure environment to prevent the resident's elopement
from the facility. These failures potentially resulted in the death of resident #1, which drowned in a lake near the
facility. Resident #1 was cognitively impaired and had a history of [REDACTED]. The facility's elopement assessment
indicated that he was a high risk for elopement. This neglect resulted in the determination of immediate jeopardy. There
were 175 residents residing in the facility.
(Refer to F224)
The facility failed to provided adequate supervision in a safe and secure environment to prevent one (resident #1) from
eloping from the facility. These failures potentially resulted in the death of resident #1. The failure to provide adequate
supervision and ensure a safe and secure environment resulted in the determination of immediate jeopardy. There were 175
residents residing in the facility.
The facility's corrective action included, adding additional staff, staff have been added across all three shifts.
Additional staff have been added to ensure no additional residents leave without facility or physician approval. Staff
members are posted at all exterior exit doors and gates 24 hours per day, 7 days per week. The facility re-inserviced staff
members across all departments on abuse, supervision and elopement policies. The inservices were completed on December 2,
3, & 4, 2015. The inservices were provided on the revised policy and procedure regarding safety and supervision of
residents, residents who are wanderers and those identified as an elopement risk. Staff sign-in sheets and policies were
provided. The facility re-inserviced staff members on disaster preparedness, fire protection, safety and the preparedness
plan on December 1, 2, 3, 4 & 5, 2015. The facility increased the hours of the front desk receptionist at the main entrance
to 7:00am-11:30PM. The elopement prevention program was re-evaluated on 12/2/15, the elopement risk form was reviewed,
residents at risk were identified and an identification binder was created for the 3 current residents at risk for
elopement. These binders were placed at the front desk, each unit and given to security personnel. The facility installed a
10 foot aluminum fence. The facility added assessments of new admissions by the risk manager and admissions nurse to ensure
accuracy. The care plans of residents at risk for elopements were revised. The facility's safety committee added a task to
complete rounds of the entire physical plant to identify any potential hazards or risk factors. This information will be
reported to the quality assurance and performance improvement committee monthly. A quality assurance/risk management
committee meeting was completed on 12/8/15 to discuss the 12/2/15 incident, and to discuss corrective actions.
F 0514 Keep accurate, complete and organized clinical records on each resident that meet
professional standards
harm or potential for actual Based on record review and staff interview, the facility failed to ensure complete and accurate medical records were
harm maintained for three (resident #1, #2, and #5) of fourteen records reviewed as evidenced by: 1) The initial resident
history and physical for resident #1 was not dated to indicate when it was completed, nursing notes were not filed in the
Residents Affected - Few closed record nor a pre-timed nursing note 2) There were duplicate conflicting entries for resident #2, and 3.) the
facility failed to ensure that the elopement risk assessments were revised quarterly and Nursing notes accurately reflected
resident #5's status.
Findings included:
1) Record review revealed resident #1 was admitted to the facility on [DATE]. A history and physical (undated) revealed,
chief complaint: Anxiety and Agitation. History: [AGE] year old male patient admitted to this facility from (name of
hospital) behavioral health unit for skilled nursing care. Medical history:[MEDICAL CONDITION](Human Immunodeficiency
Virus) Disease, Anxiety, Depression, [MEDICAL CONDITION], and Hypertension. Social history - ALF (Assisted Living Facility)
resident, poor historian. General: Awake, alert in NAD, ambulatory with shuffling gait, uses a cane occasionally. Rehab
Potential: Fair. Patient informed of medical condition: No, unable to comprehend. The history and physical was signed by
the physician, but there was no date to indicate when the physical was conducted.
During interview with the Director of Nursing (DON) on 12/8/15 at 1:00 pm and review of the clinical record for resident #1,
she confirmed there was no date in the initial history and physical. She reported, the document was signed by his primary
care physician.
During interview with resident #1's primary care physician on 12/10/15 at 10:34 am revealed, she saw this resident on
11/25/15, when I completed his history and physical. I understand there was no date on the document which was an oversight
because sometimes you are just in a hurry.
A nursing note dated 12/1/15 at 3:30 pm revealed: On arrival to 3rd floor while doing rounds resident was observed
ambulating up and down the hallway. At about 7:00 pm resident was sitting at the nursing station. At about 9-9:30 pm CNA
stated, she was unable to locate the resident in the room or on floor. I asked the CNA to check downstairs in the lobby
area, but he was not there. My co-workers and I started searching all the rooms and bathrooms on the 3rd floor. He was not
found. We went to the fourth floor and continued to search at this time. We notified the supervisor about the situation, it
was about 10:30-10:45 pm. The supervisor notified the DON who told her to notify the police. The supervisor then joined the
search. We searched all floors, stairwells, lobby, outside and around the building. We then continued the search as far as
183rd street and on the other side as for as 441. We did not see him by this time and the police arrived. We gave a
description to the officer taking the statement.
During interview with the Director of Nursing (DON) on 12/8/15 at 10:46 am and review of the nursing note dated 12/1/15 at
3:30 pm with the DON she stated, the nurse that entered the note (staff N) entered the note on 12/1/15 at 3:30 pm. She
stated, the nurse entered seeing the patient at 3:30pm. The note was written for the entire shift to report the events that
happened during the evening time of the shift. The DON could not explain how the time of the note was entered as 3:30 pm,
prior to the occurrences of some of the events on that shift.
This is the last entry in the nursing notes on file in the clinical record.
During the survey on 12/8/15 at 6:20 pm, an additional nursing note was provided by the DON who had no explanation why the
note was not included in the clinical record. She then stated, she had this note in her investigation paperwork, but said
it should be in the chart. The note was dated 12/1/15 at 12:00 midnight. The nursing note documented, Resident continues
not to be present in facility. Staff made aware of elopement and monitoring of grounds continue. 12/2/15 7 am Resident (#1)
continues not to be present in facility. Call placed to police department continues search without finding. All employees
were questioned and statements were received. Roommate unable to give statement due to cognitive status. 3:00 pm Employee
from ALF informed facility's employee that there is a body in the lake behind ALF. Immediately the Administrator informed
911 and fire rescue of findings. Immediately 911 and fire rescue arrived. Proceeded with investigation. At approximately
10:30 pm this body was identified by compliance officer as resident (#1). Call place to Dade County Guardianship program.
Message left for case manager. 12/3/15 10:45 am Guardianship Case Manager made aware of findings. DCF (Department of
Children and Family) investigator visited, facility to initiate investigation.
2) Record review of the Demographic Face Sheet revealed resident #2's date of admission was 04/07/2015. His [DIAGNOSES
REDACTED].
Record review of the physician order [REDACTED].#2 was ordered to transfer to the hospital for [DIAGNOSES REDACTED].
The Minimum Data Set (MDS) Initial dated 04/14/2015 revealed, resident #2's score in the Brief Interview for Mental Status
(BIMS) was left blank. The Functional Status codes revealed, resident was coded 4 in Self Performance (Total Dependence)
and 2 in Support (one Person physical assist) for bed mobility, Locomotion in unit, Locomotion off unit, Dressing, Eating,
Toilet use, Personal hygiene and Bathing. Coded with a 3 in Support (two + persons physical assist) for Transfer. Section B
OMB NO. 0938-0391
CORRECTION NUMBER
105469
MIAMI, FL 33179
Hearing, Speech, and Vision resident was coded as Adequate for vision (0) and with no use of corrective lenses.
Level of harm - Minimal Record review of the Court document's Restricted Letter of Guardianship of the person and property signed by a Judge on
harm or potential for actual 11/07/2013 revealed, resident #2 had a Legal Guardian from the Guardianship Program of Dade County, Inc.
harm Record review of the Fall Risk Evaluation revealed, resident #2 had duplicate Fall Risk assessments, some of them with the
same date and different scores. On 04/07/15 there were two forms with scores 18 and 19. On 05/01/15, the resident's score
Residents Affected - Few was 20. On 05/28/15, the score was 24, on 07/06/15 the score was 19. On 07/17/15, there were two different scores on a
duplicate form of 21 and 26. On 10/14/15 the score was 26 and on 11/14/15 there were two different score in duplicate forms
of 21 and 26.
Record review of resident #2's Nurses' notes dated 07/17/2015 at 10:30 am revealed, there were two different entries (none
of them labeled as a late entry). In both there was documentation of an incident where resident #2 was found on the floor,
doctor and family notified and the resident was ordered to be transferred to the hospital (both notes were written by
different persons). The nurses' notes dated randomly from the month of April to August of 2015 and some other notes from
11/14/2015 revealed, staff was monitoring and documenting the resident's condition and explaining about measures in place
to prevent the resident from falls such as educating in use of the call light. However, there was no documentation in
resident #2's records during the months of September and October of 2015.
Record review of a physician order [REDACTED].#2 was ordered to be sent to the hospital with a [DIAGNOSES REDACTED].
Record review of the Transfer and Discharge Summary dated 11/14/2015 revealed resident #2 was transferred to the hospital.
Record review of Nurses Notes dated 11/13/2015 and 11/14/2015 revealed, resident was found sitting on the floor at 3:00 am,
a laceration was noted to left eyebrow. (Those notes were not in resident #2's chart, but in the file for incident reports
kept in the Risk Manager's office.)
Interview with the Director of Nursing (DON) and Risk Manager (RM) on 12/08/2015 at 2:00 pm revealed, she was in charge of
completing the investigation of all adverse incident reports completed. The DON stated, she put inside of each file all
documentation supporting the investigation. The DON said she took all documentation from the residents' charts and she kept
everything together in the files for the Quality Assurance Committee's discussion in the monthly meeting.
3.) Review of the facility's Elopement Risk list revised on 12/09/2015, showed Residents #4, #5, and #14 as an elopement
risk. Review of the Elopement Risk Evaluation dated 09/22/2014 showed that a score of 10 or higher is at risk. The
Elopement Risk Evaluation showed that resident #5 scored a 10, and had checked off, the resident is at risk for elopement.
The last Elopement Risk Evaluation for this resident was on 09/22/2014. The resident was not re-evaluated for Elopement
risk since 09/22/2014 and re-evaluation was not completed quarterly.
Review of the Nurses notes dated 12/07/2015 for resident #5 showed checked off for Behavioral Symptoms: Wanders. The Nurses
notes did not show where, when, or interventions implemented when resident wandered.
Review of the Nurses notes dated 06/06/2015 for resident #5 showed, checked off for Behavioral Symptoms: Wanders. In the
sub-heading Diseases it was written altered mental status. The Nurses notes did not have documentation to show where, when,
or interventions implemented when resident wandered.
Review of the Nurses notes dated 05/06/2015 for resident #5 showed, checked off for Behavioral Symptoms: Wanders. In the sub
heading it was written AMS (Altered Mental Status). The sub-heading Primary [DIAGNOSES REDACTED]. The Nurses notes did
not
show where or when the interventions were implemented when resident wandered.
Review of the Social Worker notes dated on 09/29/2015 showed, Elopement still a concern and staff observes cues that would
indicate concerns with attempts to leave.
The Nurses notes did not show documentation of resident #5 attempting to leave, wander, or cues.
Review of the Annual Minimum (MDS) data set [DATE] show that resident #5 had not exhibited the behavior of wandering.
Review of the Quarterly MDS dated [DATE] showed that resident #5 has not exhibited the behavior of wandering.
Interview on 12/09/2015 at 2:20 pm with Nurse (staff A) revealed, charting was completed every day and every shift for
residents with Medicare. Staff A revealed, that the 11:00 pm to 7:00 am shift charts on residents with Medicaid. Staff A
revealed, charting is also done if the resident was on an antibiotic, or when something unusual happens with the resident.
Documentation is also completed for everyone the first 7 days of admission every shift. Staff A revealed that resident #5
is monitored for anxiousness and mood swings. Staff A revealed, that resident #5 anxious behaviors are talking fast,
yelling, aggressiveness with staff and agitation. Mood Swing behaviors are that resident #5 appears sad and has facial
expression of crying. Staff A revealed, it has been a long time since the resident exhibited these behaviors. When the
resident exhibits the behavior it was written in the Nurses notes. Staff A revealed, that when he gets aggressive and
agitated resident #5 will go down stairs and staff will have to keep watching him because resident #5 will say I am going
to my house. Staff A revealed, resident #5 is confused and it has been a long time since he wandered. Staff A revealed, he
does not remember when the last time resident #5 exhibited that behavior.
Interview on 12/11/2015 at 11:24 am with Certified Nursing Assistant (staff D) revealed, resident #5 was calm and at times
can get irritable, but most of time resident #5 is calm. Resident #5 was able to walk, and walks from his room to the
dining room. Staff D revealed, that he will just walk around but does not go into anyone's room, just walks to his room and
to the dining room. Staff D revealed, that she has not heard of resident #5 having a history of elopement.
Review of a Medicaid Resident's Weekly Documentation Schedule posted on the 3rd floor, the schedule was undated and showed,
The following resident's (White label) are to be documented on a weekly basis according to the day below. Failure to
document according to schedule will result in disciplinary action. The sheet showed that room [ROOM NUMBER] is to be
documented on Monday's, this is where resident #5 resides.

Golden Glades Inspection Report 12/11/2015

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Golden Glades Inspection Report 12/11/2015

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DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED:2/14/2018

CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

Residents Affected - Few

F 0387 Make sure that doctors visit residents regularly, as required.

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