§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 clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident's environment remained free of accident hazards for one of 21 residents reviewed (Resident 4) who resides on an alarmed unit.
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated April 14, 2025, indicated that the resident was cognitively impaired, was understood, could sometimes understand others, was independent with ambulation using a wheeled walker, was independent with mobility in a wheelchair, had a history of falls, used a wander alarm daily, and had a diagnosis of Alzheimer's dementia. The current care plan for Resident 4 revealed that the resident was at risk for elopement/wandering related to poor safety awareness and dementia/Alzheimer's disease, with interventions that included safety and location checks every 30 minutes.
A nursing note for Resident 4, dated May 26, 2025, at 6:11 p.m. revealed that he was located in the basement by laundry personnel, with his walker, wearing nonslip footwear. He was escorted back to Spruce unit without incident.
An event report for Resident 4, dated May 27, 2025, revealed that on May 26, 2025, at 5:30 p.m. the resident was found standing in the elevator with his walker in the basement. The resident was on safety and location checks every 30 minutes. His wanderguard was checked every four hours and documented on the Treatment Administration Record. He was care planned as an elopement risk/wanderer with poor safety awareness due to dementia/Alzheimer's disease. The director of the maintenance department was reaching out to the Wander Guard Company for assistance in alarming the elevator. Staff were sitting at the elevator monitoring who goes in and out of the elevator at that time.
Observations on May 29, 2025, at 9:01 a.m. and 9:51 a.m. revealed no evidence that staff were in the hallway or the lounge area monitoring the elevator on Spruce. There was no documented evidence in Resident 4's clinical record to indicate that staff were monitoring the elevator to prevent further elopements from the unit.
Interview with the Nursing Home Administrator on May 29, 2025, at 11:14 a.m. revealed that they do not have a truly secure unit. The wanderguard system by the elevator alarms if a resident with a wanderguard gets close to the elevator. Once the alarm goes off the resident may still be able to get on the elevator, but staff are aware someone may have gotten on the elevator and will begin to search.
Interview with the Nursing Home Administrator on May 29, 2025, at 11:52 a.m. revealed that they are not currently having someone sit at the elevator to monitor it, that they do not have the staff. She also revealed that she did not see Resident 4's incident on May 26, 2025, when he went off the unit, as an elopement. She indicated that all the doors to the facility have a code pad to the exits, and there was no way for the residents to exit the building unless staff punch in the code to let residents/visitors out. She indicated that on the off shifts, if a resident were to go to the basement, the doors to the therapy and activity rooms are locked. She indicated that the staff lounge is open but there is nothing in there but some tables and chairs. She again indicated that staff would be alerted when a resident with a wanderguard enters the elevator as the alarm would sound.
Physician's orders for Resident 4, dated May 22, 2025, included orders for staff to perform safety and location checks on the resident every 30 minutes. Review of the nurse aide documentation in Resident 4's clinical record for May 2025 revealed no documented evidence that the safety and location checks were completed for night shift on May 28, 2025.
Interviews with the Nursing Home Administrator and Director of Nursing on May 29, 2025, at 3:40 p.m. confirmed that there was no documented evidence that safety and location checks were completed by the nurse aides every 30 minutes on May 28, 2025, on the night shift per physician's orders and per the resident's plan of care. The Nursing Home Administrator also confirmed that staff monitoring of the elevator was added as an intervention, but they do not have staff to sit by the elevator all the time. At times, the activity staff will sit in the lounge in view of the elevator, but not all the time. The Director of Nursing indicated that she comes in early sometimes and that staff do watch the elevator. However, no staff were observed near the elevator on Spruce or in the lounge area near the elevator on Spruce this a.m.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.10(d) Resident Care Policies.
28 Pa. Code 211.12(d)(5) Nursing Services.
| | Plan of Correction - To be completed: 06/27/2025
1. Corrective Action
- Resident 4 continues to reside in the Facility with wanderguard device. 30 minutes checks were discontinued after the device was installed on the elevator as indicated below.
2. Identifying other residents
- Residents on the Spruce unit and identified as high-risk wandering residents have the potential to be affected.
3. Systemic Changes
- On 5-29-25 3rd shift until 6-2-25 @ noon when the elevator device was installed a staff member was assigned to sit at the elevator to ensure no high-risk wandering residents were able to gain access to the elevator.
- Northeast Protection Partners installed a keypad device inside the elevator cart on 6-2-25 along with Otis elevator company. Any resident who has a wanderguard that would enter the elevator cart will set an audible alarm off and the elevator will not move between floors until a staff member enters the code clearing the elevator.
- Director of Nursing (DON)/designee shall in-service all staff including agency staff regarding:
- new wanderguard security system in elevator
- elopement policy
- proper documentation for residents with orders for safety checks
- Interdisciplinary team reviewed elopement policy and remains appropriate
- Maintenance department will check elevator wanderguard system for functioning weekly
4. Monitoring
- Maintenance will audit elevator wanderguard system for functionality weekly x 3 weeks then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality assurance performance improvement committee (QAPI) for analysis and to be addressed as appropriate.
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