Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey completed on March 29, 2024, it was determined that Monroeville Rehabilitation and Wellness Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
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.
Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of seven residents (Resident R1). This was identified as past non-compliance.

Review of the facility policy "Resident Elopement" dated 6/1/23, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without knowledge of facility staff.

Review of the clinical record revealed Resident R1 was admitted to the facility on 2/13/24.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 2/20/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and Wernicke's encephalopathy (a neurological disorder caused by thiamine deficiency, and marked by mental confusion, abnormal eye movements, and unsteady gait).

Review of an "Elopement Risk Assessment" completed on 2/14/23, at 8:53 a.m. indicated Resident R1 was at risk for elopement.

Review of the physician's order dated 2/14/24, indicated Resident R1 is ordered a Wanderguard (security bracelet that alerts when an identified resident approaches a monitored door).

Review of Resident R1's plan of care for "At risk for elopement related to: Attempts to leave/exit seeking at times" initiated 3/4/24, included goals of assess for a secure unit, assess for risk of elopement per living center policy, evaluation effect of cognitive impairment upon resident's ability to understand changes in surroundings, redirect patient from doors, and take picture of patient upon admission for identification for updating elopement book.

Review of facility submitted information dated 3/17/24, at 5:16 p.m. indicated that on 3/16/24, at 6:00 p.m. "Resident R1 walked outside employee exit/entrance. Aide was under assumption he was a visitor. Resident "wanted to walk around outside." Resident then knocked on door to be let in. Resident was outside about 10 minutes. Alarm was disabled when resident walked out with visitors. Skin assessment done, no injuries noted."

Review of an employee statement written by Nurse Aide Employee E1, dated 3/17/24, indicated, "On 3/11 shift, I was walking out of a resident's room after changing them, when I seen a guy walk out of another residents room who I never recognized being down that hallway to begin with so I was under the assumption that it was a residents family member. He ended up walking to the Exit doors trying to get out, not recognizing the alarm on his ankle nor did any alarms go off as he exited the building. About ten minutes after him leaving the building is when the alarms on side 2 start going off as he came back into the facility."

On 3/16/24, the facility initiated a plan of correction that included:
-Checks every 15 minutes on Resident R1, from 3/16/24, through 3/19/24.
-Immediate head count of all residents in the facility.
-A whole house audit of all residents with updated elopement assessments completed for each resident.
-The updated list of residents identified at risk for elopement was completed and placed at each nursing unit.
-Facility-wide reeducation was completed with all staff on policies and procedures related to elopement.
-Daily clinical meetings completed on any resident with a change in condition to reevaluate for the risk of elopement.
-Daily head counts completed by the Director of Nursing or Designee to ensure residents are accounted for.
-Weekly audits for four weeks, then monthly for three months to monitor that Wanderguard bracelets are in place and functional.
-Weekly audits for four weeks, then monthly for three months to monitor that the elopement assessment and care plan is current to the resident's condition.
-Audits to be forward to the monthly Quality Assurance and Performance Improvement Committee for review.

Review of facility provided information indicated the facility staged an elopement drill on 3/18/24, at 3:05 p.m. to familiarize staff with procedures.

During an observation on 3/29/24, at 12:30 p.m. Resident R1's picture and information were present in the elopement book at the entrance/exit of the building.

During five interviews on 3/29/24, staff confirmed they received education on elopement prevention and procedures if an elopement occurs.

During an interview on 3/29/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of seven residents.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(e)(1) Management.

28 Pa. Code 201.20(b)(1) Staff Development.

28 Pa. Code 201.29(a) Resident rights.

28 Pa. Code 211.10(c)(d) Resident care policies.

28 Pa. Code 211.11(d) Resident care plan.

28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

 Plan of Correction - To be completed: 04/02/2024

Past noncompliance: no plan of correction required.

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