§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
§483.12(a) The facility must-
§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
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Observations:
Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by not providing adequate supervision for one of three residents (Resident R1) resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) from the facility.
Findings include:
Review of facility policy "Resident Protection From Abuse, Neglect, Mistreatment or Exploitation" dated 2/9/24, indicated neglect is the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide the to the resident, that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress.
Review of the clinical record indicated Resident R1 was admitted to the facility on 2/24/24.
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/29/24, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), and muscle weakness.
A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status ("BIMS", a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment
Review of Resident R1's MDS assessment dated 2/29/24, Section C0500-BIMS screening indicated a score of "5" revealing that Resident R1 had severe cognitive impairment.
Review of a Health Status Note dated 3/11/24, at 3:49 p.m. stated, "Patient continues to be confused, keeping patient near nurses station for increased supervision. Patient was found by Personal Care staff this morning after he wheeled through the cafeteria and into Personal Care, he believed he that he saw his wife."
Review of a witness statement completed by Registered Nurse (RN) Employee E2 dated 3/11/24, stated, "Resident R1 was brought back to Fairgrounds Unit by Personal Care Director. Unsure of how patient go to Personal Care. Patient remains at nurses station on Fairgrounds for increased supervision related to fall risk when patient in room alone."
Review of incidents submitted to the State indicated, "Resident R1 was found to be in the Personal Care building (attached to Skilled Facility) on the facility campus following lunch. Resident does not have an order for Leave of Absence (LOA) while admitted under his skilled stay. He exited through the Settlers dining room into the Vista Royale Personal Care building. Personal Care staff immediately returned resident back to Skilled Facility."
During an interview on 3/20/24, at 11:44 a.m. the Director of Nursing (DON) stated, "The RN Supervisor is responsible for completing the post-elopement assessment and completing a risk management form, where the staff can enter statements. The RN Supervisor would be able to complete a new Wandering Risk Assessment as part of the nursing assessment. We were not made aware that Resident R1 eloped from the facility until the following day, 3/12/24. It was a breakdown in communication, the RN Supervisor did not complete an incident report. We are not sure when exactly Resident R1 eloped from the facility and we are not sure how long Resident R1 was gone from the facility."
During an interview on 3/20/24, at 11:44 a.m. the DON confirmed that the facility did not complete an incident report and did not obtain witness statements form staff on duty at the time of Resident R1's elopement.
During a telephonic interview on 3/20/24, at 12:32 p.m. RN Supervisor Employee E1 stated, "I can't recall who was working that day, I was the supervisor until 6 p.m. I overhead someone saying that Resident R1 was found over in Personal Care. I can't recall the exact time of the day that I heard it. I asked if he was hurt and I was told he was fine, so I didn't do anything because he wasn't harmed. I said there should be a security bracelet on him. He didn't make it outside, so I didn't think it was an elopement. After a resident elopes I know to do an assessment, call the physician, complete an incident report, and update the care plan. I did not assess Resident R1 after he was brought back and I did not complete an incident report."
During a tour of the facility on 3/20/24, at 12:52 p.m. State Agency was able to exit the Fairgrounds Village Unit through the Settlers Dining Room and enter the Personal Care Home (PCH) without restricted access, walk through the entire PCH, and exit to the parking lot without having any encounter with PCH staff.
During an interview on 3/20/24, at 2:45 p.m. the Nursing Home Administrator and DON confirmed that the facility failed to ensure that residents were free from neglect by not providing adequate supervision for one of three residents (Resident R1) resulting in an elopement from the facility.
28. Pa Code 201.14(a) Responsibility of licensee.
28. Pa Code 201.18(b)(1)(e )(1) Management.
28. Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 05/02/2024
Quality Life Services, Chicora has adopted internal processes as part of our on-going commitment to provide quality care to the residents we serve. The attached information contains Quality Life Services, Chicora's Plan of Correction which we are submitting in response to specific deficiencies identified by the Pennsylvania Department of Health and is required for purposes of our facility's licensure and certification. The information and responses contained in our Plan of Correction are consistent with our own quality improvement efforts and should not be construed as an admission of or agreement with the deficiencies cited in the Department's findings. This Plan of Correction is not an admission of wrongdoing on the part of Quality Life Services, Chicora.
1. Immediate Action: Facility investigation was completed 3/20/24 and a risk management incident report was generated and was updated to reflect findings in R1's electronic record.
2. How facility identified other residents: DON/designee began a complete facility update of wander risk assessments on 3/21/24 to identify other resident's at high risk for elopement. No other residents were identified as high risk for elopement. A review of 24 hour reports as well as nurses notes will be conducted by the Director of Nursing or designee to ensure any "incident" has a risk management as well as an appropriate investigation.
3. Measures put into place: DON or designee will educate all nursing staff on abuse and neglect as well as when a risk management should be completed and identifying residents at risk for elopement and putting preventive measures in place for elopement prevention.
4. Ongoing monitoring: DON or designee will conduct a weekly audits 24 hour report and nurses notes looking for incidents/accidents to ensure a risk management is complete as well as investigation is initiated. This audit will be for 4 weeks to ensure all residents are free from abuse/neglect/mistreatment. Compliance date is May 2, 2024. Finding will be reporting in the monthly QAPI meeting for tracking and trending purposes.
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