One of the most frequently cited noncompliance deficiencies is Ftag 323, which requires a nursing facility to ensure that the resident environment remains as free of accident hazards as is possible and that each resident receive adequate supervision and assistive devices to prevent accidents. Elopements endanger residents and nursing homes in both these areas. Incidents of resident elopement frequently result in a finding of noncompliance with F-tag 323. Two recent Heath and Human Services Departmental Appeals Board cases highlight the importance of ensuring that appropriate safety measures are in place and being effectively monitored. In a May 2010 case, the board upheld a finding of noncompliance at the “immediate jeopardy” level stemming from a resident’s elopement (Dec. No. CR2134). One evening at approximately 5:30 p.m., a motorist found the 79-yearold man walking along a road a half mile from the facility. He had been diagnosed with Alzheimer’s disease, delirium, and visual problems. He took antipsychotic, antianxiety, antidepressant, and hypnotic drugs and was on a behavior-management program. Based on minimum data set responses, resident assessment protocols were triggered for wandering. The resident had been issued an alarmtriggering bracelet, and his care plan directed staff members to observe the resident’s whereabouts at all times and to check his bracelet for placement and function. After the incident, surveyors from the Centers for Medicare & Medicaid Services concluded that the resident’s bracelet had not set off the alarm when he wandered from the facility. The bracelets that the facility used were effective for only 90 days and required replacement at that time. However, the CMS noted that the facility did not have a system in place to keep track of when the bracelets were put into service or needed replacing. The facility’s policy was to check the bracelets three times daily. However, the CMS alleged that this policy was unlikely to discover that a bracelet had become inoperable at the precise minute of occurrence and that, therefore, some residents were likely to be moving within the facility with bracelets that would be inoperable until the next scheduled check. The CMS also showed that the facility was aware that many residents had the code to the keypad controlling the bracelets’ alarm and so could silence it. The agency argued that the facility should have changed the code more frequently, covered up the keypad whenever staff deactivated the alarm, instructed residents to stand back when the code was entered, or looked into alternative keypads that would preclude residents from learning the code. Finally, and perhaps most disturbingly, the CMS surveyors noted that the facility did not have a procedure in place for staff action in the event that the alarm sounded. The facility “assumed” that when an alarm sounded, a staff member would investigate the reason for the alarm and deactivate it. In addition, the facility’s policy did not require a staff member who deactivated the alarm to notify other staff. Because of the facility’s failure to implement policies to replace expired bracelets, prevent residents from obtaining the code to the alarm, and ensure that staff responded promptly and appropriately when alarms sounded, the CMS found the facility in noncompliance. The Departmental Appeals Board upheld the CMS’s finding as well as a civil money penalty in the amount of $3,050 per day until the time that the facility corrected the keypad-code problems and established new elopement protocols, a total of $264,200.