Finding Description
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to prevent a resident with a court-appointed guardian who required supervision with leave of absences, a previous elopement attempt, and wore an elopement alarm monitoring device (Resident #127) from exiting the facility unsupervised and without staff knowledge. The facility also failed to prevent a resident with impaired cognition who had a history of exit seeking behavior and wore an elopement alarm monitoring device (Resident #67) from exiting the facility unsupervised and without staff knowledge. The deficient practice was for 2 of 5 sampled residents reviewed for accidents. On 04/11/23, Resident #127 was last seen in the facility at approximately 10:30 AM walking toward the dining room. At 11:15 AM Nurse Aide (NA) #1 went to look for Resident #127 and when Resident #127 was unable to be located inside the building, a Code [NAME] (missing person) was called at 12:00 PM and a facility-wide search was conducted by staff which included the outside perimeter of the building and surrounding areas. At approximately 1:10 PM, Resident #127 was found at a location off facility property and brought back to the facility by law enforcement. On 02/02/24, Resident #67 was last observed in the facility at approximately 7:10 AM walking toward the front lobby. At approximately 7:15 AM, as NA #2 and NA #3 were leaving work they observed Resident #67 outside in the facility parking lot squatted down between two parked cars. Resident #67 was escorted back into the facility by NA #2 and NA #3. There was a high likelihood Resident #127 and Resident #67 could have suffered serious injury, harm or death when they were outside the facility unsupervised.
Findings included:
1. Resident #127 was readmitted to the facility on [DATE] with diagnoses that included diabetes, end-stage renal disease, history of falls, depression, and generalized anxiety disorder.
A State of NC Order on Motion for Appointment of Interim Guardian document dated 02/25/21 read in part, A hearing on the movant's Motion for the Appointment of an Interim Guardian was held on this day. From the evidence presented at the hearing, the Court makes the following specific findings of fact: 1) Respondent does not have capacity presently to manage medical care and appointments and has been hospitalized due to not attending medical appointments required to keep him alive, 2) Respondent is currently hospitalized with multiple serious medical conditions, and 3) Respondent will likely die if released from the hospital without assistance of a guardian. Based on these specific findings of fact, the Court concludes that there is reasonable cause to believe that the respondent is incompetent and that the respondent is in a condition that constitutes or reasonably appears to constitute an imminent or foreseeable risk of harm to the respondent's well-being, and there is immediate need for a guardian to provide consent or take other steps to protect the respondent.
A State of North Carolina Letter of Appointment Guardian of the Person document dated 04/06/21 revealed Resident #127 was assigned a court-appointed Guardian with the reason marked as incompetent person.
A care plan initiated on 06/28/19 revealed Resident #127 had a communication problem related to language barrier. His primary language is Spanish. Interventions included to notify nurse of any changes in ability to communicate and possible factors which cause/make worse/improve any communication problems, speak on an adult level clearly and slower than normal, and validate Resident #127's message by repeating aloud.
A care plan initiated on 11/18/22 revealed Resident #127 required supervision on Leave of Absence (LOA) from the facility due to poor safety awareness. Interventions included to educate Resident #127 and his Guardian on LOA policy and procedure and refer to Social Service/designee for review and reeducation if Resident #127 does not follow LOA procedures.
A care plan initiated on 12/09/22 revealed Resident #127 was at risk for injury related to an attempted elopement that was stopped by staff before he exited the building, delirium related to believing he still had an apartment locally and expressing intent to leave the facility to go to his apartment or to Florida. Interventions included to monitor and report changes in behavior such as restlessness and pacing and provide diversional activities of interest such as offering a snack or playing music he enjoys.
A care plan initiated on 12/15/22 revealed Resident #127 had an acute (sudden in onset) confusional state characterized by changes in consciousness, disorientation, environmental awareness or behavior. Resident #127 continues to have delusions and was recently started on antipsychotic medication. Interventions included to discuss feelings about placement, keep environmental noise/stimulation to a minimum, observe and report any changes in mental status, provide medications to alleviate agitation as ordered by the physician, and monitor/document side effects/effectiveness.
A care plan initiated on 04/12/23 revealed Resident #127 had an impaired ability to make self-understood related to primary language other than English. Resident #127 spoke Spanish. Interventions included to arrange for an interpreter as needed, maintain eye contact when communicating, pronounce words correctly, and use an alternative method of communication such as flip chart or translator.
A physician order for Resident #127 dated 12/20/22 read in part, check elopement alarm monitoring device via testing machine every day. The order was discontinued on 03/21/23.
A physician order for Resident #127 dated 12/20/22 read in part, visually check elopement alarm monitoring device placement every shift. The order was discontinued on 03/21/23.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #127 with intact cognition. Resident #127 was independent with walking and locomotion and displayed no behaviors during the MDS assessment period.
Review of Resident #127's medical record revealed an Elopement Assessment was completed on 12/09/22 that revealed Resident #127 was considered high risk for elopement. The assessment consisted of the following 4 sections:
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Mobility Status: Is the resident physically capable of leaving the facility? The answer was marked as 'yes.'
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Mental Status: Is resident alert and oriented times three? The answer was marked as 'no.'
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Wandering Behavior: Does the resident wander within the facility or have a history of wandering? Does the resident verbalize or exhibit exit seeking behavior? Both questions were answered 'yes.'
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History: Has there been previous history of attempted or actual elopement or unsafe wandering? The answer was marked 'yes.'
There were no further elopement assessments completed after 12/09/22 until 04/11/23.
A staff progress note dated 04/11/23 at 3:30 PM written by the Social Worker (SW) read in part, Guardian was notified of incident with Resident #127 as follows: 12:15 PM - notified facility was looking for resident; 1:38 PM - notified Resident #127 was located; 1:43 PM - notified Resident #127 was refusing to come into the facility; 2:20 PM - notified Resident #127 was sent to the hospital for involuntary commitment.
The facility's investigation included an unsigned, typed document titled, Abatement Plan, that read in part: On 04/11/23 at 12:00 PM Resident #127 was identified as being on an unauthorized absence away from the facility. The facility initiated elopement procedures and Code [NAME] for Resident #127 at 12:10 PM when he could not be located within the facility. At 12:15 PM, local law enforcement was notified that Resident #127 was missing from the facility. At 1:00 PM, Resident #127 was located at a church in the neighborhood and brought back to the facility at 1:10 PM by law enforcement. Resident #127 refused to enter the facility and at 1:30 PM was taken by law enforcement to the hospital for an evaluation and possible involuntary commitment. Resident #127 returned to the facility from the hospital on [DATE] at 8:30 PM with no new orders or treatment.
A handwritten witness statement dated 04/11/23 signed by Nurse Aide (NA) #1 read in part, I last saw Resident #127 around 10:30 AM. He was walking in the hallway as if he was going towards the dining room. After I passed Resident #127 in the hallway, I went on break. I came back around 11:00 AM - 11:15 AM and noticed he wasn't in his room or dining room. I went immediately and notified the nurse on duty that I didn't see him in either of those two places.
During a telephone interview on 04/05/24 at 11:58 AM, NA #1 confirmed she was Resident #127's assigned NA on 04/11/23 when he eloped from the facility and was told by Nurse #2 to watch him due to exit seeking behavior. NA #1 could not recall the exact time but said it was before lunch when she was doing her rounds and saw Resident #127 sitting out in the hall dressed in jeans, shirt, shoes and a jacket. She took a break and when she went back up the hall to check on him, she couldn't find him. She immediately told the Nurse, they both started looking for him everywhere and when they couldn't find him, Code [NAME] was called which she described was the facility's missing person procedure. She stated law enforcement was also notified (did not know who called), every inch of the facility was checked and then staff started searching the facility grounds and surrounding neighborhood even knocking on doors to homes in the area and stopping cars on the main road. NA #1 stated at one point during the search she recalled some staff stating he had been talking about going back to where he used to live when he was homeless and some staff (could not recall who) got into their cars, went to the location, found him and brought him back to the facility. NA #1 stated it was around 1:00 PM when Resident #127 was returned to the facility but he wouldn't go back inside so he was taken to the hospital for evaluation and believed he returned to the facility later that same day. She did not recall Resident #127 having any visible injuries or appear in any distress when he was brought back to the facility. NA #1 stated Resident #127 could make his needs known at times but had a communication barrier due to him speaking very limited English. She stated there was a staff member at the time who was fluent in Spanish and could translate for them when they (NAs) couldn't understand what it was he was needing. NA #1 stated she had provided his care frequently prior to his elopement on 4/11/23 and he had never previously displayed exit-seeking behaviors or made any attempts to leave the facility.
A witness statement dated 04/11/23 signed by Nurse #2 read in part, I last saw Resident #127 at around 10:30 AM going up the hall toward the dining room. About 11:00 AM - 11:30 AM the Nurse Aide asked where Resident #127 was and I went to look for him and could not locate him. We called a Code [NAME] and all staff started searching the facility for Resident #127.
During an interview on 04/10/24 at 9:10 AM, Nurse #2 confirmed she was Resident 127's assigned nurse on 04/11/23 when he eloped from the facility. Nurse #2 recalled she had not been employed at the facility long and was still getting to know Resident #127 and his routine which was typically keeping to himself either sitting in his room, activity room or dining room. Nurse #2 stated she never really noticed him displaying exit-seeking before 04/11/23. Nurse #1 stated on the morning of 04/11/23, Resident #127 was verbalizing wanting to leave and was observed by staff going to the exit doors. She informed the Director of Nursing (DON) and Social Worker (SW) how Resident #127 was acting and was told to keep a close eye on him. Nurse #2 instructed the NAs to keep an eye on Resident #127 and everyone did the best they could to keep him in sight. Around lunchtime, Nurse #2 stated she went to look for Resident #127 to give him his medications and couldn't find him. She along with the NAs started looking in the facility and when they couldn't find him, the Administrator and DON were notified and Code [NAME] was called. Nursing staff conducted a head count of all the residents and all staff started searching the facility premises looking for Resident #127. In addition, management staff left in their cars to search the surrounding neighborhood. Nurse #2 stated at the time of his elopement, Resident #127 had been refusing dialysis and was more confused. She was not really sure how he got out but thinks a visitor may have let him out the front door because he really didn't look like a typical resident. After Resident #127's elopement, the facility conducted elopement drills, re-education and instructed staff not to give the codes for the exit doors out to anyone who did not work at the facility.
During a telephone interview on 04/03/24 at 12:48 PM, Unit Manager #2 revealed she was no longer employed at the facility but was working on 04/11/23 when Resident #127 eloped. Unit Manager #2 recalled Resident #127 had refused to go to dialysis that day, she informed the Nurse Practitioner (NP) who ordered blood work and she (Unit Manager #2) went to Resident #127's room to draw his labs. She stated Resident #127 had started refusing to go to dialysis and when she provided him with education as to the importance of going he would still refuse, even when they tried different approaches to get him to go such as getting an outside transport company to take him because he didn't like the facility transport. Unit Manager #2 explained the more Resident #127 refused dialysis, the more confused he became and he started verbalizing he didn't want to be at the facility; however, he did not mention anything to her about wanting to leave the facility the morning of 04/11/23 when she drew his labs. Unit Manager #2 stated it was around 10:00 AM - 10:30 AM when she went into Resident #127's room and he was sitting on the side of his bed wearing a plaid shirt and jeans. She drew his labs and when she left his room, he was calm and in no distress. Unit Manger #2 stated she went on a break and then took the labs drawn to the hospital. She recalled she was only gone from the facility about 30 minutes when she was called and told Resident #127 was missing. She came back to the facility and everyone immediately started searching the facility and grounds for Resident #127. Unit Manager #2 stated she even walked around the perimeter of building but no one was able to locate Resident #127. Unit Manager #2 stated Resident #127 was later brought back to the facility by law enforcement but could not recall the time he returned. She recalled being informed Resident #127 had exited the building from the front entrance, she was not sure how, and walked to a church in the area but did not know the exact location or how far it was from the facility.
During an interview on 04/04/24 at 2:31 PM, the DON recalled she had only been employed about a month when Resident #127 eloped from the facility on 04/11/23 and she had never observed him actually attempt to leave the facility prior to that day. The DON stated she personally never heard him make comments about wanting to leave but was told by other staff that a few days prior to him leaving the facility on 04/11/23 he had made comments about wanting to go see his girlfriend. The DON recalled Resident #127 used a walker for ambulation and had an elopement alarm monitoring device attached to his walker. She was not sure why the order for the elopement alarm monitoring device was discontinued on 03/21/23 and explained when he returned from the hospital the order must not have been queued back into the system to show up as an active order. The DON stated when she saw Resident #127 the morning of 04/11/23, he wasn't acting any differently than normal and did remember seeing the elopement alarm monitoring device attached to his walker. She recalled at one point she had tried to get him to allow her to place it on his lower extremity, which only aggravated him because he knew what it was and what it meant and he had refused to wear it. When they later determined he was missing and conducted the facility-wide search, the DON stated they found the elopement alarm monitoring device on the floor in his room that looked like it had been sawed when removed from his walker which she described as torn with jagged edges. She stated facility staff searched everywhere in the facility as well as the facility grounds and when Resident #127 was not located, she (DON) drove around the neighborhood in her car to look for him. The DON did not recall how Resident #127 was able to get out of the facility but remembered being told (could not recall by who) that he had walked to some location in the area, was fed a meal and then taken to a local church where the Pastor spoke Spanish. She was not sure where Resident #127 had walked or how far the location was from the facility. The DON stated when Resident #127 was found and brought back to the facility by law enforcement, he wouldn't come inside the facility and she went with the Administrator to the Magistrates office to obtain paperwork for an Involuntary Commitment (IVC). She couldn't recall the exact time but stated Resident #127 was sent to the hospital for an evaluation but returned to the facility later that same day (04/11/23) which she stated frustrated her because she wanted him medically evaluated due to his frequent refusals to receive dialysis. The DON restated Resident #127 had a history of refusing dialysis and a few weeks after his elopement he was sent out to the hospital for evaluation and passed away. When asked if Resident #127 was safe to be outside unsupervised, the DON stated Resident #127 was able to ambulate with the use of his walker but had the tendency to have poor judgement and decision making skills.
During an interview on 04/24/24 at 2:57 PM, the Administrator explained Resident #127's primary language was Spanish which created a language barrier but he did have limited English and often made comments about wanting to go back where he used to live when he was homeless or go see his girlfriend in another state. The Administrator further explained Resident #127 had a history of refusing dialysis and as a result was deemed incompetent to make healthcare decisions and granted a court-appointed Guardian. She stated it was normal for Resident #127 to sit at the front exit doors because that was where he would wait for transportation to take him to dialysis when he was willing to go. She could not recall when but stated at one point, they had to start sending a staff member with him to dialysis because he would wander away from the dialysis center. On 04/11/23, the Administrator stated she was at the facility when notified Resident #127 could not be located, a Code [NAME] was immediately called and a facility-wide search initiated but he could not be found. The Administrator recalled NA #1 was Resident #127's assigned NA on 04/11/23 and after she returned from break around 11:15 AM NA #1 didn't see Resident #127 in his room or dining room, she notified the nurse and they both started looking for him in the facility. When the nurse and NA #1 were unable to locate Resident #127 Code [NAME] was called at 12:00 PM and law enforcement notified. The Administrator stated facility staff searched everywhere in the facility and then expanded the search to the outside grounds and perimeters. She added at the time of his elopement, Resident #127 did have an elopement alarm monitoring device but he had removed it and it was found on the floor of his room when they searched the premises. She recalled it was around 1:10 PM when Resident #127 was located and brought back to the facility by law enforcement. She stated they had informed her Resident #127 walked to one of the neighborhood homes (not sure which one), he asked the homeowners for a ride and they took Resident #127 to a local church where the Pastor spoke Spanish and the Pastor had contacted law enforcement. When Resident #127 arrived back to the facility, he sat on the bench by the front entrance door refusing to go back inside. She explained a staff member employed at the time who was fluent in Spanish was talking to Resident #127 trying to convince him to go back inside the facility but he continued to refuse stating he would kill himself because he felt he was being locked up in the facility. At 1:30 PM, she went with the DON to the Magistrate's office to obtain IVC paperwork and he was sent to the hospital for evaluation but returned to the facility later that same day (04/11/23) and even though they felt he was too high functioning, he was moved to a room on the locked Memory Care Unit for safety. The Administrator stated after Resident #127's elopement, they did a root cause analysis and the best they could determine was some family members had learned the codes to the exit doors and must have let him out thinking he was a visitor because he didn't look like a typical resident of the facility. She stated they changed all the codes to the exit doors on 04/11/23 and facility staff were instructed not to give out the code to anyone and cover their hands when entering the code. The Administrator stated prior to his elopement, Resident #127 had been declining due to his frequent refusals of dialysis and sometime after returning to the facility on [DATE] he went on Hospice care, was sent out to the hospital in May 2023 and later passed away while at the hospital.
An observation of the facility grounds was conducted on 04/10/24 08:40 AM. The front of the building sat just off a main road that inclined and curved throughout a residential area with a speed limit of 35 miles per hour. When standing at the front entrance, there was border wall on the opposite side of a circular driveway that led to/from the parking lot located on the right side of the building. There was also a sidewalk that started at the front entrance of the facility and along the side of the building to the parking area. At the end of the sidewalk and driveway was an exit on the left out to the main road and on the right was the facility sign and the parking lot. Houses and/or trees bordered the opposite side of the parking lot, back and left side of the building.
An online website named Weather Underground was used to obtain the outside weather in the Hendersonville area on 04/11/23 which noted at 10:54 AM the temperature was 59 degrees Fahrenheit (F), at 11:54 AM the temperature was 63 degrees F, at 12:54 PM the temperature was 66 degrees F, and at 1:54 PM the temperature was 68 degrees F.
2. Resident #67 was admitted to the facility on [DATE] with diagnoses that included vascular dementia moderate with psychotic disturbance, bipolar disorder and hallucinations.
A physician order for Resident #67 dated 12/12/23 read in part, check elopement alarm monitoring device via testing machine every day.
A care plan initiated on 12/11/23 revealed Resident #67 has a diagnosis of vascular dementia, traumatic brain injury and behaviors which include, in part: wandering, rejecting care, packing up belongings and attempting to leave the facility using the fire exit button to open doors and becoming combative with staff when they attempt to prevent her from leaving. Interventions included one-to-one, every 15 minutes and/or every 30 minutes monitoring for safety as needed, attempt to redirect if/when she is resisting care, and monitor/report/document any mood changes to the nurse.
A care plan initiated on 12/11/23 revealed Resident #67 had a diagnosis of vascular dementia which could cause her cognition to vary throughout the day requiring assistance with decisions. Interventions included reorient to date, time and place if appropriate, provide redirection if/when Resident #67 made inappropriate actions and monitor/report/document any changes in cognition.
A care plan initiated on 12/12/23 revealed Resident #67 was at risk for elopement due to wandering, vascular dementia, traumatic brain injury, increased confusion at night, may be looking for family, thinks she works at the facility, and elopement alarm monitoring device to right ankle. Interventions included: may leave building when accompanied by staff or responsible adult, notify the Physician or Nurse Practitioner of exiting behavior, provide diversional activity PRN, and redirect from exit doors.
A care plan initiated on 12/12/23 revealed Resident #67 had impaired cognitive function and thought processes related to dementia and head injury. Interventions included for staff to cue, reorient and supervise Resident #67 PRN.
An activities of daily living Care Area Assessment (CAA) associated with the Minimum Data Set (MDS) assessment dated [DATE] read in part, Resident #67 has had no documented behavioral issues since admission. Per staff interview, Resident #67 will wander throughout the unit and at times, will push on exit doors. Resident #67 does wear an elopement alarm monitoring device for added safety. She was transferred from another facility due to working at that facility and knowing the codes to open the facility's exit doors.
A physician order for Resident #67 dated 01/04/24 read in part, visually check elopement alarm monitoring device placement to right ankle every shift.
The quarterly MDS assessment dated [DATE] assessed Resident #67 with moderate impairment in cognition. Resident #67 displayed no behaviors, was independent with walking and used an elopement alarm daily during the MDS assessment period.
Review of Resident #67's February 2024 Treatment Administration Record (TAR) revealed physician orders for staff to check the elopement alarm monitoring device via testing machine every day shift and to visually check the elopement alarm monitoring device placement to her right ankle every shift. Both orders were initialed as completed daily per physician order. On 02/04/24, Resident #67's elopement alarm monitoring device was noted functioning and intact on the right ankle, each shift.
Review of Resident #67's medical record revealed an Elopement Assessment was completed on 03/06/24 that revealed Resident #67 was considered high risk for elopement. The assessment consisted of the following 4 sections:
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Mobility Status: Is the resident physically capable of leaving the facility? The answer was marked as 'yes.'
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Mental Status: Is resident alert and oriented times three? The answer was marked as 'no.'
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Wandering Behavior: Does the resident wander within the facility or have a history of wandering? Does the resident verbalize or exhibit exit seeking behavior? Both questions were answered 'yes.'
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History: Has there been previous history of attempted or actual elopement or unsafe wandering? The answer was marked 'yes.'
A staff progress note dated 02/02/24 at 5:34 AM written by Nurse #3 read in part, Resident #67 woke up at 4:00 AM and has been exit-seeking ever since. Resident #67 gathered all her belongings and said, I'm going home and no amount of redirection would convince her otherwise. All staff have been alert and monitoring her movement between front and back/side exit. Resident #67 also seems to be aware that if you consistently push the door it will open and has been observed several times leaning her weight on the door.
Telephone attempts for an interview with Nurse #3 on 04/05/24 at 10:16 AM, 04/10/24 at 10:16 AM and 04/10/24 at 12:14 PM were unsuccessful.
A staff progress note dated 02/02/24 at 7:51 AM written by Unit Manager #1 read in part, Resident #67 was found in the parking lot outside of the facility hiding between two cars. One-to-one immediate intervention initiated. Resident #67 was assessed with no injuries. Family and Nurse Practitioner were notified.
During an interview on 04/10/24 at 10:48 AM, Unit Manager #1 recalled on 02/02/24 at shift change, around 7:00 AM, she was notified by Nurse Aide (NA) #2 and NA #3 that Resident #67 was found outside the building in the parking lot. Unit Manager #1 stated upon assessment, Resident #67 had no injuries or signs of distress and was placed on one-to-one staff supervision. She was unable to recall what Resident #67's response was when asked why she went outside. Unit Manager #1 explained Resident #67 always went to the exit doors trying to get out stating she wanted to leave to go see her boyfriend.
The facility's investigation included an unsigned, typed document titled, Abatement Plan, that read in part: Resident #67 exited the building on 02/02/24. Resident #67 had an elopement alarm monitoring device in place; however, the door did not alarm due to Resident #67 entering the code and a malfunction of the elopement alarm monitoring device sensor did not trigger the locking mechanism. Resident #67 was out of the facility for less than 5 minutes and was seen in the parking lot by staff and brought back inside the facility. Resident #67 had no injuries.
A witness statement dated 02/02/24 obtained from the Receptionist read in part, Resident #67 was at the front door trying to push it open to get out when I arrived about 6:45 AM. She had all her clothes in bags. I went down to the nurses' station and had her moved from door before I left the door. When I was walking back up to my office, I saw NA #2 and NA #3 walking Resident #67 back down the hall. I had told them at the desk Resident #67 was up there trying to get out. They said she had been at the other door also during the night trying to get out. It was about 7ish when NA #2 and NA #3 found Resident #67 out in the parking lot. Resident #67 had let herself out.
During a telephone interview on 04/10/24 at 10:31 AM, the Receptionist recalled on 02/02/24 she had just arrived at the facility at approximately 7:00 AM and as she was coming through the front entrance, Resident #67 was standing by the door inside the facility, fully dressed with all her belongings packed in bags. The Receptionist stated she opened the door, making sure it closed behind her, and told Resident #67 she needed to go back to her room and not be standing by the door. The Receptionist went down the hall to clock in and then stopped by the nurses' station per her usual routine to see if there were any discharges. As she was walking back up the hall toward the front where her office was located, she saw NA #2 and NA #3 walking Resident #67 down the hall. She recalled the NAs stating Resident #67 had gotten outside and they had found her in the parking lot. The Receptionist stated it was only about 10 minutes after she saw Resident #67 at the door when the NAs had brought her back into the building. She was not sure how Resident #67 got out of the building because she (Receptionist) made sure the key pad was covered when she entered the code to the door and the door had closed securely before she left the area. The Receptionist explained Resident #67 used to be a NA at another facility and could figure out the codes to the exit doors. She further stated it was normal routine for Resident #67 to push on the exit doors or try to enter codes to get the doors open and staff provided her with frequent redirection throughout the day. She stated Resident #67 was always cooperative with staff redirection but due to her cognition, it wasn't long before she was right back at the exit doors. The Receptionist stated right after it was discovered Resident #67 had gotten out of the building, she sat by the door until it was fixed that day by the Maintenance Director. In addition, staff received immediate re-education on elopement process/procedure, not giving out the codes to the exit doors and making sure you covered your hand when entering the code.
A witness statement da[TRUNCATED]