§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 and select facility policy, observations, and staff and resident interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor a resident's whereabouts and prevent an elopement by one resident (Resident 181) out of 14 sampled residents, placing the 65 residents out of 238 residents residing in the facility, identified at risk for elopement, including Resident 142, in immediate jeopardy to their health and safety.
Findings include:
Review of facility policy entitled "Elopement/ Unauthorized absence", last revised by the facility February 6, 2024, revealed that elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The facility will identify residents with potential/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility will implement its policies and procedures promptly to locate the resident in a timely manner.
The corresponding procedures included:
-all residents will be assessed for the risk of elopement
-residents identified at risk will have interventions promptly implemented to reduce the risk of elopement
-residents identified at risk will have their picture and face sheet form placed in the binder that is kept in an area accessible by staff.
Upon determining that a resident cannot be located, a head count (of residents) will be conducted. If the resident is still missing, "code green" using the resident name, room number and unit name will be announced. The clinical supervisor or designee will notify the administrator, the Director of Nursing and the attending Physician. The highest-ranking staff member becomes the "Team Leader" and coordinates the search process. If the resident is not located on the premises, the team leader will direct staff to conduct an external search.
A review of a facility policy "Resident leave of absence" revised April 25, 2024 revealed, that a "leave of absence" is defined as, time away from the facility, either on or off the property, where the resident is not under the direct care or supervision of facility staff, regardless of the amount of time, and someone other than facility stff has assumed responsibility for the resident during such time.
Corresponding procedures were noted as:
-The resident/responsible party will be requested to sign-out of the facility, which indicates the resident's/responsible party's acceptance of responsibility for self/resident while participating in an LOA and reminded to sign back in and alert staff upon return.
-prior to leaving the facility, the charge nurse will request the address and phone number of the location where the resident will be, if known and estimated date and time of return.
A review of the clinical record revealed that Resident 181 was admitted to the facility on April 30, 2024, with diagnoses, which included bipolar disorder ( a mental health condition that causes extreme mood swings between depression and mania or hypomania) and difficulty walking. The resident was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status a score of 13-15 indicates intact cognition). He independently propelled on the nursing unit in the wheelchair. The resident was homeless prior to this recent admission to the facility.
When reviewed at that time of the survey ending May 31, 2024, there was no evidence that an elopement risk assessment had been completed upon the resident's admission or at any time prior to his elopement from the facility.
There was also no documented evidence at the time of the survey ending May 31, 2024, of a physician order permitting the resident to go out on a leave of absence.
An anonymous facility employee reported a concern to the State Survey Agency reporting that on Saturday May 18, 2024, Resident 181, a resident residing on the second floor of the the Blue building (facility is comprised of two facilities on the same campus), left the facility unsupervised, without staff knowledge, and walked independently with his cane, traveling approximately 0.5 miles to a convience store. The nursing supervisor was called, found him brought him back to the building, but staff did not document the incident in the resident's clinical record.
A review of Resident 181's clinical record, conducted during the survey on May 31, 2024, confirmed that there was no documentation in the resident's clinical record regarding the resident's elopement.
Observation and interview conducted on May 31, 2024 at 10 AM revealed that Resident 181 was in his room on the second floor of the Blue building seated in his wheelchair. In the presence of the surveyor, Resident 181 wheeled to the nurses station and signed his name and the time in the "resident sign out book." There was no nursing staff at the nurses desk or anywhere in the immediate vicinity at that time. The resident and the surveyor then entered the elevator, exited on the first floor, passed the front desk (which was also unattended at that time) and wheeled outside through front entrance into the parking lot area.
An interview at that with Resident 181, revealed that he stated that on Saturday May 18, 2024, early in the morning he signed the Leave of Absence (LOA) sheet, in the binder on the nurses desk (on the second floor resident unit). He stated that there was no nursing staff in the area at the time he signed out. He also stated that he goes out of the building several times a day, unaccompanied, stating that he does not tell anyone he is leaving the floor.
Resident 181 stated that on Saturday May 18, 2024 he left the second floor in his wheelchair and had his cane with him. He took the elevator downstairs and left the building through the front entrance. When he got outside, he stood up from his wheelchair, and walked with his cane off the facility campus. He stated that it took him "about" an hour to walk from the facility to the convience store, stopping 4 to 5 times, sitting on the curb to rest. He stated that when he got to the store, he was shopping and he was approached by " a gang of people" from the facility. He stated that he was approached by a male nurse from the facility as well as 2 female nurse aides. These employees took him in a car and brought him back to the facility. He stated that the male nurse yelled at him and "took his outside privledges away." Resident
181 stated that he is not steady on his feet and it was not easy to walk, and that he had to cross a busy street to get to the convenience store.
Interview May 31, 2024 at 11:15 AM Employee 6, a nurse aide, stated that she worked 7 AM to 3 PM on Saturday May 18, 2024. She explained that residents who are independent can sign themselves out in a book that is at the nursing station, to go outside. Therapy and other services also use this book to sign residents off the unit. Employee 6 said, but if a resident leaves LOA (leave of Absence) there are papers to be signed in the resident's medical record. She stated sometimes people forget to sign in and/or out in this book, and staff have at times, needed to search for a resident because they didn't sign out. She stated she went on break with another aide sometime between 9:30 AM and 10:30 AM heading to a nearby convience store. While traveling in the car they noticed a resident sitting on the curb at the convience store. They returned to the facility and told the nursing supervisor that they saw the resident at the convience store. The nursing supervisor and two other staff members went to get the resident. Employee 6 stated she never saw any other employees with the resident or near the resident when they saw him sitting on the curb. She also stated that no facility staff member had asked her for a witness statement to give her account of the incident.
An interview with Employee 7, a nurse aide, conducted at approximately 11:00 AM on May 31, 2024, revealed that she worked on Saturday May 18, 2024, during 7 AM to 3 PM shift. Employee 7 stated that she had not taken care of the resident who eloped, but recalled hearing the Code Green (the facility's elopement code) sound and she participated in performing a head count and checked rooms for the missing resident, but were unable to find him. She stated that she heard the resident was found at the convience store and was returned to the facility. She stated no facility staff member had asked her for a witness statement as part of an investigation into incident.
An interview with Employee 1, a nurse aide, on May 31, 2024, at 11:15 AM revealed the employee was working the dayshift on May 18, 2024. The employee stated the facility called a Code Green, the code called when a resident elopes from the facility. Employee 1 stated they began to look for the resident. Employee 1 stated she did not find him but heard he was found at the Turkey Hill down the street. Employee 1 stated that when residents are leaving the unit, they are supposed to sign out in the book that sits on the nursing station. She stated that the book is not "supervised" and at times, staff doesn't know who has signed themselves off the units. Employee 1 stated that if they are looking for a resident and cannot find them, they will check the book to see if they signed out. Employee 1 stated that there is no real procedure for ensuring the residents are signing the book or staff monitoring when residents are leaving the unit.
An interview with Employee 2, LPN, (license practical nurse) on May 31, 2024, at 11:25 AM revealed this nurse was working the dayshift on May 18, 2024. Employee 2 stated that Resident 181 went out for fresh air during the first cigarette break around 8:30 AM. Employee 2 stated that Employee 3, RN, called a Code Green when the resident could not be found on the unit. Another employee who was on break saw the resident at the Turkey Hill down the street. Employee 2 stated that the resident was brought back to the facility at approximately 9:30 AM. Employee 2 stated that the resident was allowed to sign the book on the unit and go outsides on the facility grounds for fresh air independently. Employee 2 stated that staff don't monitor the book unless they need to check on a specific resident, and there is no procedure in place to ensure residents are signing the book and staff monitoring to ensure the residents return to the unit.
An interview with Employee 4, nurse aide, on May 31, 2024, at 11:35 AM revealed the employee was working the dayshift on May 18, 2024. Employee 4 stated that while she was on her 15 minute break, she went to Dunkin Donuts to get a coffee. The employee stated when she was leaving Dunkin Donuts to return to the facility, she spotted the resident sitting on the curb at the Turkey Hill. The employee stated the resident was alone in the parking lot of the store, with no staff with him or nearby. Employee 4 stated that she did not see him outside in the facility parking lot prior to him leaving the facility and did not see him outside for the morning smoke break. Employee 4 stated that she came back to the facility and told Employee 3 (RN) and Employee 5 RN that the resident was at the Turkey hill. Employee 3 called a Code Green, and he drove his car down to the Turkey Hill to pick the resident up. Employee 4 stated that there is no procedure in place to supervise residents signing out to leave the unit and confirm their return. The employee stated the residents are not supervised and sign themselves out. Employee 4 stated that if they can't find a resident, they would look in the book to see if they signed themselves off the unit. Employee 4 stated there have been times when a resident was not on the unit but did not sign off in the book.
There was no evidence that the facility had interviewed their staff to determine when staff had last seen the resident, or how he was able to exit the nursing unit and building without staff awareness of the resident's whereabouts. The facility failed to demonstrate that staff adequately monitored this resident's whereabouts and activities. Nursing staff outside the building on a break called the facility to inform the facility staff that the resident had left the building as facility staff were unaware and the duration of the resident's absence could not be determined due to the lack of investigation by the facility.
At the time of the survey ending May 31, 2024, the facility had not investigated the incident to determine the circumstances and how long the resident was gone.
Interview with the Director of Nursing on May 31, 2024, at approximately 2:00 PM, revealed that staff had informed her of the incident and she came into the facility on May 18, 2024. The DON confirmed that the facility failed to provide necessary supervision and implement effective safety measures for this resident. The DON also confirmed that the facility failed to investigate the resident's elopement to prevent recurrence and the incident was documented in the resident's clinical record or reported to the State Survey Agency.
A review of the "LOA" binder located at the second floor nurses desk revealed on May 31, 2024, revealed the names of residents who signed out to leave the floor independently on multiple days. The residents' names were not listed on the list of residents approved to sign out and leave the floor independently provided during the survey by facility administration. This was confirmed during the survey by the DON and NHA on May 31, 2024, at 11:30 AM. Further, at the time of the survey of May 31, 2024, facility administration could not locate the sign-out sheet for May 18, 2024.
Clinical record review revealed that Resident 142 was admitted to the facility on November 16, 2021, with diagnoses to include schizophrenia, anxiety, major depression, bipolar disorder and difficulty walking and was moderately, cognitively impaired with a BIMS score of 10 (8012 indicates moderate cognitive impairment).
A review of the LOA binder located on the second floor nurses station, revealed that May 29, 30 and 31, 2024, Resident 142 signed herself and left the floor.
Review of the resident's clinical record revealed no evidence that the resident could leave the floor and the facility independently, which was confirmed by Director of Nursing during interview on May 31, 2024, at 1 PM.
Immediate Jeopardy was called on May 31, 2024, due to the facility's failure to timely identify resident absences from the facility and prevent elopements. Lack of functioning operational procedures for monitoring residents who are signing out to leave the unit, building and facility grounds.
The facility was notified of the Immediate Jeopardy on May 31, 2024, at 1:30 PM and the IJ template provided to the facility.
An immediate plan of correction was requested and received on May 31, 2024.
The plan included:
- Identify residents who go outside independently and have the ability to be affected
-policy and procedure reviewed with residents affected to ensure they know the process for leaving the unit
-Therapy screen current residents affected to ensure they are able to leave safely
-Residents with cognitive impairment will be reviewed to ensure the elopement assessments are accurate and interventions are in place to prevent elopement
-review of current residents to ensure residents have an appropriate LOA order, if issues identified, call Physician for appropriate orders
-Staff were made aware if a resident is not independent to go off the unit and outside and ensured they knew the policy for leaving the unit and/or LOA, Staff were educated that is a resident is not independently able to leave the unit, they must be stopped and supervision provided.
-current staff educated on the LOA policy/procedure and the elopement policy and procedure
-elopement drill completed on all shifts
The Immediate Jeopardy was lifted on May 31, 2024, at 4:40 PM when the removal plan was verified as completed.
28 Pa. Code 201.18 (e)(1) Management
28 Pa. Code 211.12 (c)(d)(5) Nursing services
28 Pa. Code 211.10 (a)(c)(d) Resident care policies
| | Plan of Correction - To be completed: 06/12/2024
1. Resident #181 was returned to facility without incident. No ill effects noted to resident.
2. To identify like resident that have the potential to be affected, the DON/designee reviewed current residents to ensure an appropriate LOA order was in place for residents that leave the unit, go outside on the grounds, and or go on LOA independently.
To identify like residents that have the potential to be affected, the DON/designee completed elopement assessments on current residents to ensure they are current and if not they were updated to reflect current status. Elopement books were reviewed to ensure it was up to date with the appropriate residents who are at risk for elopement. Elopement drills were completed on all shifts x 24 hours.
3. To prevent this from happening again the SW/designee will educate current residents on the LOA policy for those residents identified as independent to go off unit, go outside on grounds, and or LOA independently to ensure they know the policy for leaving the unit, going outside and or LOA independently.
To prevent this from happening again the SDC/designee will educate current staff on system implemented on the LOA policy for those identified residents as independent to go off unit, go outside on grounds, and or LOA independently to ensure they know the policy for residents leaving the unit, going outside and or LOA. Changes in residents with independent LOA orders will be updated in CMM. Binders on the units for signing out will be updated by the SW.
To prevent this from happening again the SDC/designee will educate current staff on the elopement policy to ensure staff are knowledgeable of what constitutes and elopement and what to do in an event of an elopement.
4. To monitor and maintain ongoing compliance the SW/designee will interview 10 capable residents with Independent Loa orders, to leave the unit, go outside, or LOA weekly x 4 then monthly x 2 to ensure they know the appropriate procedure.
To monitor and maintain ongoing compliance the DON/designee will interview ten employees in weekly x 4 then monthly x2 to ensure they are aware of the process for residents with independent LOA orders to go off unit, outside, or LOA independently.
To monitor and maintain ongoing compliance the NHA/designee will interview ten current employees weekly x 4 then monthly x2 to ensure employees are knowledgeable of the elopement policy.
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