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.
Based on review of clinical records, facility documentation, and policy and procedures, and staff interviews, it was determined that the facility failed to implement sufficient monitoring interventions and supervision to prevent elopement (unauthorized leave from the facility). This failure placed residents at the facility in an Immediate Jeopardy situation for two of three residents reviewed who eloped from the facility (Closed Residents CR1 and CR2).
Review of the facility policy entitled, "Elopement/ Unauthorized Absence Policy," dated 10/03/2019, defined elopement as leaving the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The policy also indicated that the facility would: conduct an elopement assessment for each resident on admission, quarterly and as needed; identify residents receiving a score of four or more as "at risk;" have prompt interventions for residents identified as at risk; notify the physician of the risk and recommended interventions; notify the responsible party; and place a picture and face sheet in a binder kept in an area accessible by staff.
Resident CR2's clinical record revealed an admission date of 9/17/2020, with diagnoses including Parkinson's Disease (progressive nervous system disorder that affects movement), Bipolar Disorder (mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), Schizophrenia (serious mental disorder in which people interpret reality abnormally), and cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions).
A Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 9/17/2020, identified Resident CR2 with a Brief Interview for Mental Status (BIMS) score of 15 and cognitively intact.
Review of progress notes revealed the following documentation:
-On 11/29/2020, at 11:06 a.m. Resident CR2 was anxious all night; swinging and got down the elevator to the first floor; and was attempting to get out the doors; noted he/she was hitting the chair with his/her fist; thought his/her mother and father are downstairs to take him/her to a mental hospital today to lock him/her away; he/she stated he/she is going to jail for killing them.
-On 12/01/2020, at 11:37 a.m. therapy staff observed Resident CR2 attempting to open a window and jump out of it. Resident CR2 stated he/she was trying to escape the facility and stated that Resident CR2 had made multiple attempts in the past few days to exit the building.
An elopement assessment completed on 12/01/2020, (after his/her attempt to crawl out the window) resulted in a score of eight (high risk). An elopement care plan was initiated on 12/01/2020, which included interventions of 1:1 (one-on-one), every 15-minute or every 30-minute monitoring for safety if applicable; use distraction; and Wanderguard (electronic band programmed to alarm when the resident approaches an outside door) if applicable.
Review of Resident CR2's progress notes revealed the following documentation:
-On 12/03/2020, at 1:47 p.m. the Interdisciplinary Team (IDT) identified Resident CR2 as an elopement risk, he/she verbalized wanting to leave, and that staff would continue with the Wanderguard.
-On 12/06/2020, at 9:22 a.m. Resident CR2 refused medications, was agitated, anxiously walked up and down the hallways, and was unable to be redirected.
-On 12/06/2020, at 9:45 a.m. Resident CR2 eloped from the facility and was returned by staff at approximately 10:00 a.m.
Review of information dated 12/06/2020, submitted by the facility, revealed the following information:
...At 9:45 a.m. the resident was seen sitting at the nurse's station in his/her wheelchair a few minutes later the empty wheelchair was sitting at the nurse's station. Staff immediately checked resident's room to determine if he/she had returned to his/her room or bathroom. The resident was not in either area....Wandergard system alarming at this time on first floor.... resident had been identified as an elopement risk...
There was no evidence that Resident CR2's safety interventions to prevent elopement of a 1:1 or every 15-minute, or every 30-minute monitoring between 12/01/2020, and 12/06/2020, had occurred prior to Resident CR2's elopement from the facility.
The December 2020 Treatment Administration Record (TAR) identified to check placement and functioning of the Wanderguard as an unscheduled "other" order, however did not include a method for staff to identify that they had checked the Wanderguard as ordered.
During an interview on 3/04/2021, at 2:45 p.m. Licensed Practical Nurse (LPN), Medical Records Employee E1 confirmed there was no evidence for 1:1, every 15-minute, or every 30-minute monitoring, and checking placement and functioning of the Wanderguard on the TAR between 12/01/2020, and 12/06/2020.
During an interview on 3/04/2021, at 4:02 p.m. the Nursing Home Administrator (NHA) confirmed there was no evidence for 1:1, every 15-minute, or every 30-minute monitoring, and checking placement and functioning of the Wanderguard on the TAR between 12/01/2020, and 12/06/2020.
The facility failed to implement identified interventions to prevent Resident CR2's elopement from the facility on 12/06/2020.
Resident CR1's clinical record revealed an admission date of 2/24/2021, with diagnoses that included being unsteady on feet, muscle weakness, multiple chemical dependencies, bladder cancer, sepsis (bacteria in the blood), and pneumonia (infection in the lung). Resident CR1's clinical record contained an admission elopement assessment completed on 2/24/2021, with a score of six (high risk). Further review revealed a physician's order dated 2/24/2021, for a Wanderguard and check for placement and functioning every shift.
Resident CR1's MDS dated 2/27/2021, identified a BIMS of 15, cognitively intact.
Review of progress notes revealed the following documentation:
-On 2/24/2021, at 1:00 p.m. the admission nursing assessment identified that Resident CR1 was alert to person, place, and time, was independent with functioning, was exit seeking near exit door after being requested to go into room, and that the Wanderguard bracelet is intact and functional.
-On 2/24/2021, at 3:46 p.m. a progress note stated that Resident CR1 was very agitated coming out of his/her room, leaving the isolation area, trying to get on the elevator, and was not redirected easily.
-On 2/24/2021, at 4:06 p.m. a Social Services progress note stated that Resident CR1 was pacing short hall on 2nd floor causing outside door to alarm, the cause of the alarm activation was reviewed with Resident CR1 and he/she was agreeable and voiced understanding, and that Social Services placed Resident CR1's picture and demographic sheet in elopement books on 1st, 2nd and 3rd floors and initiated a care plan.
An elopement care plan reviewed on 3/5/2021, did not identify the use of the Wanderguard or to check for its placement and functioning every shift. Interventions included: activities to keep occupied, calmly redirect resident, divert resident attention, and relocate resident to a different area.
The February 2021 TAR lacked evidence that Resident CR1's Wanderguard was checked for placement and functioning for three out of 11 shifts prior to the date of elopement on 2/28/2021.
Resident CR1's clinical record lacked further evidence regarding monitoring his/her exit seeking behaviors between 2/24/2021, and 2/28/2021. There was no evidence of implementation of the care plan interventions.
Review of information dated 2/28/2021, submitted by the facility, identified the following information:
Resident had left the facility unauthorized and without notifying staff. The Wanderguard had been torn/cut off and left on a tray table...A search of the facility grounds was conducted and staff noted a homemade rope extending out a third floor window and down the side of the building. Upon inspection, it was determined that the resident had cut/torn a bath blanket into strips then tied them together and either repelled or lowered himself to ground level. When the window was inspected it was determined that the resident had broken the window stop from the metal frame either by slamming the window against it or with an object. The window stop was still intact and found on the window ledge. The window screen was kicked out. The resident did not return to the facility.
Resident CR1 was exhibiting exit seeking behaviors and the facility failed to implement the appropriate supervision and interventions to prevent him/her from eloping on 2/28/2021.
An Immediate Jeopardy (IJ) situation was identified to the NHA on 3/11/2021, at 8:10 p.m. and the IJ template was provided to the NHA, related to Resident CR2 and Resident CR1's elopements from the facility. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to ensure implementation of all supervision and safety measures to prevent elopement for residents in the facility and an immediate action plan was requested.
On 3/11/2021, at 11:54 p.m. an acceptable immediate action plan was approved which included the following interventions:
1. On 2/28/2021, the Administrator and Maintenance Director fixed the window in the room that the resident went out unauthorized and inspected all other windows in the facility to ensure that all safety stops were intact.
2. On 2/28/2021, the facility completed an unusual occurrence report. An investigation was started immediately, and root cause completed. Statements were obtained from employees on duty.
3. To identify other like residents, on 2/28/21 the DON/designee completed a house-wide audit of elopement assessments of all and ensure that the elopement binders are updated.
4. On 2/28/2021, an elopement drill was conducted, and will be conducted every shift within the 24 hrs. The facility will conduct a weekly elopement drill for four weeks then quarterly per policy.
5. On 2/28/2021, the Social Worker or designee will review and update care plans for high elopement risk residents. All elopement risks will be reviewed by the Medical Director and only residents identified as continued risk with a past elopement will have an order for 15-minute checks as needed when a risk deemed.
6. On 2/28/2021, the therapy/speech department reviewed all residents Brief Interview for Mental Status (BIMS) and updated care plans as needed.
7. On 2/28/2021, to prevent this from recurring, the Director of Nursing and designee provided education to all staff re: elopement policy, admission care plan meeting, and BIM scores on admission. Initiated again on 3/11/21, and continue prior to employees starting their shift.
8. On 2/28/2021, the Activity Director completed an emergency resident council meeting room-to-room and informed residents that they would need to complete a Leave of Absence (LOA) to leave the facility if going on a pass.
9. On 2/28/2021, that facility conducted a whole house BIMS re-assessment. Beginning 3/11/21, the Interdisciplinary Team (IDT) will monitor BIMS scores every week for four weeks, then monthly for three months to ensure that the facility maintains compliance.
10. All elopement care plans were updated on 2/28/21, will be reviewed weekly at IDT meetings and updated as necessary.
11. The facility changed the exterior door codes on 3/11/21, and will continue to change every two weeks and document.
12. On 3/11/21, a full house elopement assessment was completed and will be completed once per week for four weeks, then monthly times three months.
13. Education of nursing staff and managers if a resident expresses a want to leave the facility, notify the resident of their right to discharge against medical advice (AMA), notify the physician, family, and appropriate authorities, have the resident sign the AMA and discharge was completed 3/11/21, and continue prior to employees starting their shift.
14. Education of nursing staff on order entry scheduling was initiated on 3/11/21, and education will continue prior to employees starting their shift.
15. Placed AMA documents at both nurse's stations and the front lobby on 3/11/21.
16. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held on 2/28/21, with Medical Director and IDT.
17. On 3/11/21, any further every 15-minute checks will be directed by the physician.
18. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
After review of facility documentation, observations, and staff interviews, the implementation of the above stated action plan was confirmed on 3/12/2021, at 3:40 p.m. and the NHA was informed that the Immediate Jeopardy situation was removed.
28 Pa. Code 201.14(a) Responsibility of Licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 211.11 (d) Resident Care Plan
28 Pa. Code 211.12 (d) (5) Nursing Services
| ||Plan of Correction - To be completed: 04/09/2021|
This plan of correction is prepared because it is required by State and Federal law and not because Edison Manor Nursing and Rehabilitation Center agrees with the allegations and citations listed on pages 1-24 of this statement of deficiencies (SOD). Edison Manor Nursing and Rehabilitation Center does not admit any deficiency is present. This plan of correction shall operate as Edison Manor Nursing and Rehabilitation Center's written credible allegation of compliance effective 5pm on April 9, 2021.
CR1, CR2, and R3 have discharged from the facility. The NHA/MD fixed the window in the room that was compromised and inspected all other windows in the facility to ensure the stops were intact. The facility completed an unusual occurrence report, the investigation began and a root cause was identified. An initial elopement drill was conducted and further conducted every shift for 24 hours. The activity director completed and emergency resident council meeting to review LOA paperwork. All exterior door codes were changed.
An updated elopement assessment was completed on all residents and elopement binders were reviewed to ensure accuracy with resident identifiers. The social worker completed a review and updated care plans on residents identified as at risk for elopement. The facility completed a BIMS reassessment on all residents, the speech therapist and social worker reviewed all BIMS and updated care plans as necessary.
On 2/28/21 staff were educated on elopement policy, admission care plan meeting, and BIMS scores on admission. On 3/11/21 this education was initiated again and continued prior to employees starting their shift. On 3/11/21 nursing managers were educated regarding AMA, notification of MD, family, and appropriate authorities as well as the need for the resident to sign the AMA discharge papers. AMA documents were placed at the front desk and at both nursing units. Nursing staff was educated on order entry and scheduling. Wanderguard's will be checked for placement and function each shift with documentation in TAR. 15 minute checks will be ordered by physician, no current residents have 15 minute checks ordered.
The NHA/DON or designee will be responsible for ongoing compliance monitoring. The facility is ensuring interventions are in place by conducting/auditing weekly elopement drills (a test to ensure staff know the correct way to respond to a resident leaving the facility) for four weeks and then quarterly, BIMS scores will be monitored for four weeks and then quarterly(this monitoring will provide facility notice of change/increase for elopement) , Elopement assessments will be completed weekly for four weeks and elopement care plans will be reviewed for four weeks at the inner disciplinary team meeting, Exterior door codes will be changed every two weeks. Policy given to corporate for review, no revision at this time. Facility to complete a directed in-service regarding the supervision and safety of residents on 4/9/21 with outline, PowerPoint, and posttest being delivered by an approved vendor.
The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.