§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and
§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
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Observations:
Based on review of facility policy, clinical records, incident reports and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of eleven residents (Closed Record Resident CR1).
Findings include:
Review of the facility policy "Accidents and Incidents" dated 12/11/23, indicated all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the premises shall be investigated and reported to the Nursing Home Administrator.
Review of the facility policy "Wandering and Elopements" dated 12/11/23, indicated:
The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.
-If a resident is missing, initiate the elopement/missing resident emergency procedure.
-Determine if the resident is out on an authorized leave.
-If the resident was not authorized to leave, initiate a search of the building and premises,
-If the resident is not located, notify the administrator and the director of nursing services, the legal representative, the attending physician, law enforcement, and local department of health.
Review of the admission record indicated Resident CR1 was admitted to the facility on 10/20/23. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/8/24, indicated the diagnoses of stroke, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), history of alcohol abuse, high blood pressure, and chronic pain syndrome.
Review of Resident CR1's Elopement Risk Assessment dated 1/29/24, indicated resident was not at risk for elopement.
Review of Resident CR1's physician orders dated 3/18/24, failed to indicate an order for leave of absence from the facility.
Review of Resident CR1's care plan initiated on 11/18/23, indicated discharge planning - discharge to the most appropriate level of care. Evaluate care needs and potential for discharge.
Review of Resident CR1's practitioner progress note dated 2/16/24, at 11:32 p.m. as a late entry indicated resident presented with a functional decline and has been limited due to vision impairments and is excited by current improvement at this time after cataract surgery. Ambulating (walking) 300-400 feet with front wheeled walker.
Review of facility provided event report dated 3/5/24, at 5:00 p.m. indicated on the evening of 3/4/24, alert and oriented Resident CR1 was realized to be off the unit for a prolonged period, causing the nursing staff to enact the elopement protocol. Resident was not able to be found. Resident was last seen around 8:30 a.m. when they ate their breakfast. Interview with the resident's roommate indicated Resident CR1 got dressed up in the morning like she was going to somewhere. When she asked her where she was going, Resident CR1 stated "mind her business". Prior to cataract surgery, Resident CR1 did not go out of the facility on any leave of absence, nor had she requested a leave of absence for any reason, so no order for such had been obtained.
Further review indicated Resident CR1 had recent cataract surgery which has improved her ambulation and activities of daily living. Resident in prone to skipping meals and ordering take out. Resident attends activities frequently and was last seen dressed in all black with a jacket on and an orange purse. Attire was appropriate for the weather.
Resident CR1 was observed at the gas station across the street from the facility on 3/6/24, at 10:46 a.m. and told the facility employee "Tell everyone hello. I'm okay and will return to the facility someday".
The Nursing Home Administrator caught up with Resident CR1 in his personal vehicle on 3/6/24, and attempted to talk resident into returning to the facility. Resident CR1 declined and refused to sign the Against Medical Advice (AMA) Discharge papers. Resident indicated she was staying with a friend, being taken care of, has money, a place to stay, food, and everything that she needs. Resident had no fears or concerns.
Review of Registered Nurse (RN) Employee E1's Witness statement dated 3/4/24, indicated resident seen this morning at approximately 7:45 a.m. in room sitting on bed. Received her morning medications and was waiting for breakfast. RN Employee E1 continued to pass medications to the unit. Resident missed her afternoon medications and thought to be activities we she often was on the third floor.
Review of Nurse Aide (NA) Employee E2's Witness statement dated 3/4/24, indicated Resident CR1was seen around 8:00 -8:15 a.m. when breakfast was delivered. Resident seemed in good spirits. NA Employee E2 did not see resident the remainder of the shift due to taking care of her assigned residents and resident attending activities provided by the facility.
Review of Licensed Practical Nurse (LPN) Employee E3's witness statement indicated the shift started at 3:15 p.m. and two residents were missing from her assignment, and she was told they were at activities. Both were due for medications and only one returned for them. LPN Employee E3 went to the third floor to retrieve Resident CR1 from activities and did not see resident. We started searching for her.
Observation on 3/18/24, at 8:25 a.m. the front entrance lobby door was secured, and Survey Agency (SA) had gained access to the facility by the receptionist unlocking the front door.
Interview on 3/18/24, at 10:00 a.m. LPN Employee E4 indicated Resident CR1 was just sitting there in front of the desk like any other normal day, the next thing I looked, and she was gone.
Interview on 3/18/24, at 10:05 a.m. NA Employee E5 indicated "Resident CR1 just up and snuck out of here one day. Resident was sitting right there in front of the nursing station and the next time I looked she was gone. She would always go down to activities, so I just assumed she was there. She often ordered out for food and wouldn't return to the unit until dinnertime from the Activity Room on the third floor. I guess she got her eyes fixed and decided she didn't need to be here anymore".
Interview on 3/18/24, at 10:18 a.m. Receptionist Employee E6 revealed pictures of residents who are wander risks actively in the facility at the front desk. Indicated, "It happens sometimes, they try to get out, but I can't physically touch them". Nursing is called as soon as possible if somebody slips through during the scheduled smoking times.
Interview on 3/18/24, at 12:25 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for one of eleven residents (Closed Record Resident CR1).
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.29(a)(c)(d) Resident rights.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.
| | Plan of Correction - To be completed: 04/24/2024
WeCare at Penn acknowledges receipt of the Statement of Deficiencies and proposes this Plan of Correction to the extent that the summary of findings is factually correct and to maintain compliance with applicable rules and provisions of quality of care of residents.
The Plan of Correction is submitted as a written allegation of compliance. WeCare at Penn's response to this Statement of Deficiencies does not denote agreement with the Statement of Deficiencies nor does it constitute an admission that any deficiency is accurate. Further, WeCare at Penn reserves the right to refute any of the deficiencies on this Statement of Deficiencies through Informal Dispute Resolution, formal appeal procedure and/or any other administrative or legal proceeding.
CR1 remains discharged from the facility despite request for her to return.
Current resident records were reviewed to ensure elopement assessment is current and a leave of absence (LOA) order is present, if appropriate.
Director of Nursing (DON) and/or designee will provide education to nursing staff regarding the facility policies associated with tag F 689 and accidents and incidents and elopements.
Registered Nurse (RN) Supervisor and/or designee to audit for safe wandering throughout facility weekly for 4 weeks and then monthly for 2 months.
Results of the monitoring will be reported through the facility Quality Assurance Meetings.
Date of Compliance: 4/24/24
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