Observations:
Based on a review of clinical records, facility investigative reports, and employee job descriptions, as well as staff interviews, it was determined that the facility's administration, Nursing Home Administrator and Director of Nursing, failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental functioning of residents in the facility by failing to monitor one resident's whereabouts and prevent an elopement for one (Resident 3) allowing the resident to exit the building, placing the resident at risk for serious harm which created an Immediate Jeopardy situation.
Findings included:
A review of the job description for the Nursing Home Administrator, undated, revealed that the administrator manages the overall operations of the skilled nursing facility by performing the following duties personally or through subordinate supervisors.
The position responsibilities include the overall direction, coordination, and evaluation of all departments, carries out supervisory responsibilities in accordance with the organization's policies and applicable laws.
The facility failed to ensure these responsibilities were carried out, as evidenced by the elopement of Resident 3. This demonstrated a lack of effective oversight to address identified elopement risks for at-risk residents.
The Job Description for Direction of Nursing Services, undated, indicated that the Director of Nursing is responsible for the overall direction, coordination, and evaluation of all units, and carries out supervisory responsibilities in accordance with the organization's policies and applicable laws.
The position responsibilities include evaluate the education and training needs of all nursing personnel and personally conducts monthly meetings, in service education programs as needed, or directs training through subordinate staff, coordinates infection control activities, oversees nurse aide registry and eligibility and oversees the educational program, and works with the clinical team to provide positive clinical outcomes and seamless transitions in care levels.
The DON failed to provide adequate monitoring or to implement effective interventions to prevent Resident 3's elopement and unsafe exit from the facility.
Based on the findings the facility's inability to implement and enforce policies to monitor Resident 3 and address elopement risks resulted in Immediate Jeopardy to the health and safety of residents identified as at risk for elopement. This demonstrates a systemic failure in the administration's oversight and resource allocation to ensure a safe environment for residents.
The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F689) 483.25(d)(1)(2) Accidents, revealed the facility's administration did not fulfill essential job duties to ensure resident safety and regulatory compliance. This included a failure to evaluate and mitigate risks associated with elopement for identified at-risk residents.
Refer F689
28 Pa. Code: 201.14 (a) Responsibility of licensee
28 Pa. Code: 201.18 (b)(1)(3) (e)(1) Management
28 Pa. Code 211.12 (c)(d)(1) (2)(3)(5)Nursing services
| | Plan of Correction - To be completed: 11/07/2025
An education session will be conducted for the Executive Director/Nursing Home Administrator (NHA) and Director of Nursing (DON) with an external consultant on the responsibility of the administration to promote resident safety and maintain the highest level of physical and mental functioning of the residents through deployment of their resources, including an overview of policies and procedures that address resident safety to ensure compliance with standards of practice and that resident safety and highest practicable function of residents is included. The external consultant will also review the State Operations Manual – Appendix Q as part of the education process.
The Executive Director (NHA) or designee will conduct a review of the job descriptions for the Executive Director (NHA) and Director of Nursing (DON) with recommendations to update the "Essential Duties and Responsibility" to include ensuring the use of resources effectively and efficiently to attain or maintain he highest practice physical, mental and psychosocial well-being of each resident.
The Executive Director (NHA) facilitated and conducted an ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting on October 31st, 2025 that included the Executive Director (NHA), Director of Nursing, facility Medical Director and other committee members. The committee assigned the Director of Nursing (DON) or designee to initiate a review of the Wander guard Policy dated May 20, 2016, and the Elopement Risk Observation and Prevention policy dated August 15, 2016. The committee assigned the Executive Director (NHA) or designee to initiate a review of the Federal Regulation F689 with all department managers to ensure responsibilities to prevent accidents and maintain the safety of the residents through supervision at the level to which they have been educated and trained.
Recommended updates by the DON and NHA will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee and the internal Risk Management department monthly for three months for review and approval. The QAPI Committee meetings will continue at least quarterly and address concerns or questions from department managers. Any policy modifications will require staff training completed by the Director of Nursing or designee.
|
