Pennsylvania Department of Health
QUALITY LIFE SERVICES - CHICORA
Patient Care Inspection Results

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QUALITY LIFE SERVICES - CHICORA
Inspection Results For:

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QUALITY LIFE SERVICES - CHICORA - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to one complaint and an incident, completed on March 20, 2024, it was determined that Quality Life Services - Chicora 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:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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.
483.12 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;
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.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
483.12(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,

483.12(b)(4) Establish coordination with the QAPI program required under 483.75.

483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect 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. All reports of abuse, neglect, exploitation, or mistreatment including injuries of unknown source, and misappropriation or resident property will be investigated and documented.

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."

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 an interview on 3/20/24, at 2:45 p.m. the Nursing Home Administrator and DON confirmed that the facility failed to failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect 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(e)(1) Management.


 Plan of Correction - To be completed: 05/02/2024

1. Immediate Action: Facility investigation was completed 3/20/24 according to facility policy and procedure for "Resident Protection from Abuse, Neglect, Mistreatment or Exploitation" and a risk management incident report 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. 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 the facility's abuse and neglect policy as well as when a risk management should be completed to ensure compliance. A progressive disciplinary policy will be followed for those who fail to follow the policy.
4. Ongoing monitoring: DON or designee will conduct a weekly audits of 24 hour report and nurses notes looking for incidents/accidents to ensure a risk management is complete as well as investigation is initiated according to facility policy. 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.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:
Based on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) to rule out neglect for one of three residents (Resident R1).

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. All reports of abuse, neglect, exploitation, or mistreatment including injuries of unknown source, and misappropriation or resident property will be investigated and documented.

Review of facility policy "Elopement Prevention" dated 2/9/24, indicated the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Upon admission, readmission, quarterly and as necessary, nurses will complete a Wandering Risk Assessment. Should the resident's behavior warrant elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the resident's stay and modifications will be made to the care plan and prevention techniques.

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 the clinical record failed to indicate a physical assessment, vital signs, and a Wandering Risk Assessment were completely after Resident R1 was returned to the facility by Personal Care staff.

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 an interview on 3/20/24, at 2:45 p.m. the Nursing Home Administrator and DON confirmed that the facility failed to conduct a thorough investigation of an elopement to rule out neglect for one of three residents (Resident R1).

28 Pa Code: 201.18 (e)(1)(2) Management

28 Pa Code: 201.29 (a )(c)(d) Resident Rights

28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services


 Plan of Correction - To be completed: 05/02/2024

1. Immediate Action: Facility investigation was completed 3/20/24 and a risk management incident report was updated to reflect findings in R1's electronic record.
2. How facility identified other residents: A baseline audit of all incidents/accidents that occurred between 2/28/2024 3/28/24 was conducted to ensure a complete investigation occurred and was documented appropriately in the medical record.
3. Measures put into place: DON or designee will educate all nursing staff on the proper procedure for completing an investigation following an incident. A progressive disciplinary policy will be followed for those who fail to follow the policy. Education will be provided to the DON by the Clinical Consultant on when to investigate and proper techniques to investigate.
4. Ongoing monitoring: DON or designee will conduct a weekly audit of incidents/accidents for 4 weeks to ensure a complete and timely investigation occurred. Finding will be reporting in the monthly QAPI meeting for tracking and trending purposes. Compliance date is May 2, 2024.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:
Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs after a resident eloped (resident exits to an unsupervised or unauthorized area without the facility's knowledge) from the facility for one of three residents (Resident R1).

Findings include:

Review of facility policy "Elopement Prevention" dated 2/9/24, indicated the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Upon admission, readmission, quarterly and as necessary, nurses will complete a Wandering Risk Assessment. Should the resident's behavior warrant elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the resident's stay and modifications will be made to the care plan and prevention techniques.

Review of facility policy "Care Plan and Interdisciplinary Care Conferences" dated 2/9/24, indicated the care plan is reviewed and updated at least quarterly, and is based on ongoing assessment and evaluation of resident needs. It may be specifically reviewed up and updated as the resident's condition changes, when there are resident/family concerns, when there are newly identified risk factors, because of a resident's response to current interventions.

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."

A review of Resident R1's care plan on 3/20/24, failed to include goals and interventions related to Resident R1's elopement on 3/11/24.

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 an interview on 3/20/24, at 1:30 p.m. the Director of Nursing confirmed that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs after a resident eloped from the facility for one of three residents (Resident R1).

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(d)(3) Nursing services


 Plan of Correction - To be completed: 05/02/2024

1. Immediate Action: R1's care plan was updated to include a focus, goal, and interventions for an increased wandering risk on 3/25/24.
2. How facility identified other residents: DON or designee will complete a full facility audit for all incidents/accidents that occurred 2/28/2024 3/28/24 to ensure all resident care plans have been updated.
3. Measures put into place: DON or designee will educate all nursing staff on requirements for care plan reviews and revisions at routine intervals and following any change in condition or resident event.
4. Ongoing monitoring: DON or designee will conduct weekly audits x 4 weeks for care plan review and revision on all residents who have experienced an incident or accident. Compliance date is May 2, 2024. Finding will be reporting in the monthly QAPI meeting for tracking and trending purposes.

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.
Observations:
Based on review of facility documents, facility policy, clinical records, 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 three residents (Resident R1).

Findings include:

Based on facility policy "Elopement Prevention" dated 2/9/24, indicated the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Upon admission, readmission, quarterly and as necessary, nurses will complete a Wandering Risk Assessment. Should the resident's behavior warrant elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the resident's stay and modifications will be made to the care plan and prevention techniques.

Review of facility policy "Accidents and Incidents" dated 2/9/24, indicated an accident/incident is any happening, which is not consistent with routine operations or the routine care of the particular resident. When a resident incident/accident occurs, the resident will be assessed by a Registered Nurse (RN). The Charge Nurse or designee will complete a risk management report noting witnesses, if applicable, and notes of any corrective action, and that the family and physician were notified. The licensed nurse responsible for the resident will update resident's plan of care as necessary related to the incident/accident.

Review of the facility "Registered Nurse" job description indicated the RN is to ensure accurate documentation of all incidents/accidents occurring during the shift and report problems to the Director of Nursing (DON) and assist in developing and implementing corrective actions.

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 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 the clinical record failed to indicate a physical assessment, vital signs, and a Wandering Risk Assessment were completed after Resident R1 was returned to the facility by Personal Care staff.

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 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 (NHA) and DON confirmed that the facility failed to make certain each resident receives adequate supervision that resulted in an elopement for one of three residents (Resident R1).

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

28 Pa. Code 201.18(b)(1)(3) Management.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.


 Plan of Correction - To be completed: 05/02/2024

1. Immediate Action: On 3/21/24 the DON began a full facility update for wander risk assessments. On 3/22/24 the DON completed a wandering risk assessment on R1 which showed a score of 4.0 (low risk) compared to 2.0 on 3/2/24.
2. How facility identified other residents: An audit of all updated wander risk assessments occurred to identify any resident with a newly identified wandering risk to ensure adequate interventions are in place to prevent elopement. Residents will be assessed for risk of wandering on admission, quarterly and with any significant change in status.
3. Measures put into place: DON or designee will educate all nursing staff on the facility policy for elopement prevention and completion of the wander risk assessment.
4. Ongoing monitoring: DON or designee will conduct a weekly audit of all new admissions and residents with a change in condition weekly x 4 weeks to ensure that a wander risk assessment has been completed and the appropriate interventions were put into place to prevent elopements. Finding will be reporting in the monthly QAPI meeting for tracking and trending purposes. Compliance date is May 2, 2024.


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