Pennsylvania Department of Health
AVENTURA AT PROSPECT
Patient Care Inspection Results

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AVENTURA AT PROSPECT
Inspection Results For:

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AVENTURA AT PROSPECT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to three complaints and a reportable incident, completed on April 2, 2024, it was determined that Aventura at Prospect, 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 related to the health portion of the survey process.



 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
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 clinical records, interview with resident and staff, and review of facility policies, it was determined that the facility failed to adequately supervise one of six residents reviewed (Resident R2), who was able to board a bus and train and elope from the facility. This failure placed Resident R2 at high risk for injury and resulted in an Immediate Jeopardy situation. (Resident R2)

Findings include:

Review of the facility's policy title "Elopement/ Missing Resident" revealed that it is goal of the facility to provide a safe environment and to identify residents who are at risk for elopement. It strives to prevent harm while maintaining the least restrictive environment for residents.

Under the heading "Responsibility" it stated that it is the responsibility of all staff members to report any residents suspected of not being in the facility, or attempting to leave the building, without checking out, in accordance with established policies immediately.

Review of facility's policy titled "Resident LOA" revealed staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. The policy also stated that restrictions noted on the resident's chart concerning who may not sign the resident, must be honored unless otherwise prohibited by facility policy or state/federal law governing such releases.

Review of Resident R2's clinical record revealed the resident was admitted to the facility on January 30, 2024, with a diagnoses of personality disorder, type 2 diabetes mellitus (failure of the body to produce insulin to enable sugar to pass from the blood steam to cells), non-hodgkin lymphoma (a type of cancer that begins in your lymphatic system, which is part of the body's germ-fighting immune system) and major depression (loss of interest in pleasurable activities) and morbid (severe) obesity.

Review of Resident R2's hospital discharge documentation dated January 12, 2024, revealed admitting diagnosis of suicidal ideation with a plan. Resident R2 was at the hospital for a 302 petition (an emergency involuntary examination and treatment when there is a reasonable belief that a person is severely mentally disabled to the extent that immediate treatment is required). Further review revealed 5 previous psychiatric hospitalizations this year. One of those suicidal attempts resulted in the resident in a coma in the Intensive Care Unit.

Review of an elopement assessment completed January 31, 2024, revealed that the resident was assessed as not a risk for elopement.

Review of Resident R2's Minimum Data Set (MDS- assessment of resident care needs) completed March 5, 2024, revealed that the resident was assessed with a BIMS (Brief Interview of Mental Status) score of 14, which indicated that the resident was cognitively intact.

Review of Resident R2's care plan initiated January 30, 2024, revealed that the resident had a potential for falls related to a decline in functional status/ambulation dysfunction. The interventions included to assist with transfers.

Review of Resident R2's clinical record revealed a physician order from March 13, 2024, stating "Resident may NOT go out LOA (leave of absence) unaccompanied" and on March 21, 2024, stating 'Resident may go out LOA with a responsible adult."

Review of physician note dated March 19, 2024, revealed resident reported history of paranoid delusions and hearing voices.

Review of the physician note dated March 23, 2024, noted that the resident needs a chaperone if going LOA.

Review of Resident R2's electronic clinical record revealed under the census tab on "Hospital Leave."

Continued review of the resident's clinical record revealed that the last note written in the resident's clinical record was on March 26, 2024, at 11:04 p.m. "Resident has eloped on yesterday 3/25. Resident has not returned during this shift." The nursing note was struk out.

Interview with the Director of Nursing, Employee E2, on April 1, 2024, at 1:24 p.m. revealed on March 25, 2024, resident left the facility by herself or AMA (against medical advice). She is cognitive enough to sign herself out and no staff members checked to see if a family or friend was here to pick her up. Facility realized resident was gone after the police called the facility to say she was in the Emergency department at a hospital in New Jersey. Police informed the facility that the resident took a bus and train to New Jersey. Facility arranged to pick up resident from the hospital however resident voluntarily committed herself to the hospital. Resident left all belongings including her cell phone at the facility.

Interview with Director of Nursing, Employee E2 on April 1, 2024, at 2:15 p.m. stated that the resident often knows the code to the secure doors even when the facility changes them. Director of Nursing and Nursing Home Administrator are unsure how resident was able to leave facility since the front door needs a code. It was revealed during interview that Resident R2 was not officially documented as AMA (against medical advice) and no AMA paperwork was signed. The facility considered resident AMA since she left on her own.

Further during interview with the Director of Nursing, Employee E2 revealed that there was no list at the front desk of residents with a physician order to be able to leave the facility for leave of absences (LOA) that the front desk receptionist can refer to. The proper procedure for leave of absence is for the 'responsible adult' of the resident to sign out on a log with the receptionist at the front desk.

Review of Leave of Absence Release for Resident R2 revealed on March 25, 2024, at 6:46 p.m. under the heading 'Signature of person accepting responsibility for resident' there was a signature of Resident R2 .

Based on the above findings, an Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator (NHA) on March 1, 2024, at 3:27 p.m. and an immediate action plan was requested. The Immediate Jeopardy template was provided to the Nursing Home Administrator.

On April 4, 2024, at 8:08 p.m. the facility's immediate action plan was accepted. The facility's action plan included the following:

1. The identified resident is not in the facility at this time.
2. Residents who have an order that they may go on a LOA were educated on facility sign in/ sign out procedures by DON on March 26, 2024.
3. Wandering risk assessments were completed on all current residents on March 26, 2024.
4. Elopement risk care plans were updated for all current residents as appropriate by MDS on March 26, 2024.
5. Resident council meeting held to discuss the sign in/sign out policy by DON on March 26, 2024.
6. Ad-hoc QAPI completed with medical Director and QAPI team on March 27, 2024 on ensuring resides leaving the facility user proper LOA procedures and ensuring residents do not leave the facility unattended without staff or guardian supervision.
7. All door codes in facility changed.
8. NHA and ADON immediately began providing education to clinical staff regarding the facility policy for Elopement/ Missing Resident. The facility will complete 80% prior to the end of day April 4, 2024 with all staff, Staff will receive this education prior to starting their next scheduled shift until 100% of all staff are trained and educated.
9. Receptionists will be re-educated on the process for letting residents out of the building.
10. Facility will identify all others in the population with the potential to be affected by this deficient practice by 100% audit of all residents at risk for elopement and residents who have physician's order for leave of absence.
11. Facility will audit all residents who are identified at risk for elopement to ensure proper supervision is provided. 100% of all resident discharged will be reviewed daily x 7 days, weekly x 4 weeks then monthly x 2.
12. Facility will audit all residents who have physician's order for leave of absence to ensure proper supervision is provided based on order. 100% of all residents with physician's order for leave of absences will be reviewed daily x 7 days, weekly x 4 weeks then monthly x 2.
13. Facility will complete audits on doors to ensure proper functioning of egress alarm daily x 7 days, weekly x 4 weeks then monthly x 2.
14. Any tends identified in these audits will be reported to the facility QAPI committee and this plan of correction will be modified to address those trends as needed.
15. Facility will conduct elopement drill April 2, 2024, then every month x 3 months.
16. The facility Ad Hoc QAPI committee will review facility policies related to Missing Resident/ Elopement and Leave of Absence to ensure they adhere to state and federal requirements for proper supervision by end of day April 2, 2024.

Interviews were conducted with facility staff on April 2, 2024, between 2:05 p.m.- 4:40 p.m. to verify the implementation of the action plan. Facility staff was able to verbalize what they would do if they found a resident with exit seeking behaviors, and the proper procedure for alerting management and police. Other facility residents interviewed on they verbalized their understanding of LOA policy. Review was conducted of the education provided to facility staff related to resident elopement.

Following the verification of the immediate action plan the Immediate Jeopardy was lifted on April 2, 2024, at 5:45 p.m.



28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Coe 201.18(b)(3) Management

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12(c) Nursing services

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










 Plan of Correction - To be completed: 04/24/2024

1. The identified resident did not return to the facility.
2. Residents who have an order that they may go on a LOA were educated on facility sign in/ sign out procedures by DON
3. Wandering risk assessments were completed on all current residents
4. Elopement risk care plans were updated for all current residents as appropriate by MDS
5. Resident council meeting held to discuss the sign in/sign out policy by DON
6. Ad-hoc QAPI completed with medical Director and QAPI team on ensuring resides leaving the facility user proper LOA procedures and ensuring residents do not leave the facility unattended without staff or guardian supervision.
7. All door codes in facility changed.
8. NHA and ADON immediately began providing education to clinical staff regarding the facility policy for Elopement/ Missing Resident. The facility will complete 80% prior to the end of day April 4, 2024 with all staff, Staff will receive this education prior to starting their next scheduled shift until 100% of all staff are trained and educated.
9. Receptionists will be educated on the process for letting residents out of the building.
10. Facility will identify all others in the population with the potential to be affected by this deficient practice by 100% audit of all residents at risk for elopement and residents who have physician's order for leave of absence.
11. Facility will audit all residents who are identified at risk for elopement to ensure proper supervision is provided. 100% of all residents discharged will be audited weekly x 4 weeks then monthly x 2.
12. Facility will audit all residents who have physician's order for leave of absence to ensure proper supervision is provided based on order. 100% of all residents with physician's order for leave of absences will be reviewed weekly x 4 weeks then monthly x 2.
13. Facility will complete audits on doors to ensure proper functioning of egress alarm weekly x 4 weeks then monthly x 2.
14. Any tends identified in these audits will be reported to the facility QAPI committee and this plan of correction will be modified to address those trends as needed.
15. Facility will conduct elopement drill April 2, 2024, then every month x 3 months.
16. The facility Ad Hoc QAPI committee will review facility policies related to Missing Resident/ Elopement and Leave of Absence to ensure they adhere to state and federal requirements for proper supervision by end of day April 2, 2024.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

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 policies, review of facility documentation, clinical record review and interviews with residents and staff, it was determined that the facility failed to ensure that an elopement incident and a transfer to the hospital as a result of a possible drug overdose were reported the the State Survey Agency for two of six residents reviewed (Resident R1 and Resident R2).

Findings include:

Review of facility, "Abuse Policy" revised April 20, 2023, revealed that " Administrator or designee is responsible for operationalizing all policies and procedures that prohibit abuse and neglect. They are also required to report instances of suspected or actual abuse or neglect occurring within the facility. "

Review of the clinical record for Resident R1 revealed that she was admitted to the facility on March 18, 2024, for care after pelvic fracture from being struck by a motor vehicle. Further review of Resident R1's clinical record revealed a history of substance abuse.

Review of nursing note by Licensed nurse, Employee E41, dated March 20, 2024, at 10:30 p.m. which indicated caregivers were in Resident R1's room providing incontinent care. Resident R1 stated that her boyfriend gave her heroin. Employee E41 and the supervisor were alerted. Pulse Ox 87% (A pulse oximeter measures your blood oxygen levels and pulse) a non-rebreather mask (device used to deliver a high concentration of oxygen) and oxygen at 15 liters per minute. Pulse Ox taken again at 96%. Resident R1 appeared more alert, Narcan administered at 4 milligrams. Resident sent out for further evaluation for possible heroin overdose. Resident R1 left facility at 10:40 p.m. by 911 (Emergency Medical Services) stretcher ambulance accompanied by four medical attendants.

Further review of Resident R1's clinical record revealed a nursing note Registered nurse, Employee E48, Supervisor, dated March 20, 2024, at 10:45 p.m. which indicated that she was notified by the 3-11 nurse aide and licensed nurse that Resident R1 was alert but lethargic and had a grey pallor with shallow respirations of 10-12. Resident R1 stated in a low whisper that her boyfriend came and gave her a gram of brown heroin in a piece of cardboard which she snorted in her right nostril. Staff confirmed that she had a visitor between 7:00 p.m. and 8 p.m. Oxygen with a non-rebreather mask was in place and Narcan was administered and 911 was called. Call to provider with order to send Resident R1 to the Emergency Room. Verbal report given to ER (Emergency Room) Nurse. Local police and EMT (Emergency Medical Team) arrived, verbal report given, pertinent medical records sent with EMT. Resident R1 was transferred to the Emergency Room. Resident R1's sister was notified by voicemail. Medications secured in medication cart and personal belongings stored in room. No obvious illegal drugs or drug paraphernalia observed in resident's room.

Interview with Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 1, 2024, at 10:40 a.m. revealed that no investigation was done for the March 20, 2024, incident, that she was alert and oriented and that a friend brought the drugs into the facility, and that she was sent out to be evaluated. When asked again about the investigation and if it was reported to the State Agency, the DON stated that no formal investigation was done. The NHA added that the incident was not reported the the PA Department of Health.

Review of Resident R2's clinical record revealed the resident was admitted to the facility on January 30, 2024, with a diagnoses of personality disorder, type 2 diabetes mellitus (failure of the body to produce insulin to enable sugar to pass from the blood steam to cells), non-hodgkin lymphoma (a type of cancer that begins in your lymphatic system, which is part of the body's germ-fighting immune system) and major depression.

Review of Resident R2's Minimum Data Set (MDS- assessment of resident care needs) completed March 5, 2024, revealed that the resident was assessed with a BIMS (Brief Interview of Mental Status) score of 14, which indicated that the resident was cognitively intact.

Review of Resident R2's clinical record revealed a physician order from March 13, 2024 stating "Resident may NOT go out LOA (leave of absence) unaccompanied" and on March 21, 2024 stating 'Resident may go out LOA with a responsible adult."

Review of the physician note dated March 23, 2024, noted that the resident needs a chaperone if going LOA.

Review of Resident R2's electronic clinical record revealed under the census tab on "Hospital Leave."

Continue review of the resident's clinical record revealed that the last note written in the resident's clinical record was on March 26, 2024 at 11:04 p.m. "Resident has eloped on yesterday 3/25. Resident has not returned during this shift." The nursing note was struck out.

Interview with the Director of Nursing, Employee E2, on April 1, 2024 at 1:24 p.m. revealed on March 25, 2024 resident left the facility by herself or AMA (against medical advice). She is cognitive enough to sign herself out and no staff members checked to see if a family or friend was here to pick her up. Facility realized resident was gone after the police called the facility to say she was in the Emergency department at a hospital in New Jersey. Police informed the facility that the resident took a bus and train to New Jersey. Facility arranged to pick up resident from the hospital however resident voluntarily committed herself to the hospital. Resident left all belongings including her cell phone at the facility.

Interview with Director of Nursing, Employee E2 on April 1, 2024, at 2:15 p.m. stated that the resident often know the code to the secure doors even when the facility changes them. Director of Nursing and Nursing Home Administrator are unsure how resident was able to leave facility since the front door needs a code. It was revealed during interview that Resident R2 was not officially documented as AMA (against medical advise) and no AMA paperwork was signed. The facility considered resident AMA since she left on her own. Director of Nursing, Employee E2 revealed they did not report the event to the Department of Health.



28 Pa. Code 201.14(a) Responsibility of licensee

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







 Plan of Correction - To be completed: 04/26/2024

Facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 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.

NHA will be educated by vice president of clinical operations on proper notification of reporting of alleged violations.

DON or designee will audit facility reportable to ensure they are reported timely, weekly x4, then monthly x2 after. All findings will be brought to QAPI.
483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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.
483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:

Based on observations, staff interviews, and a review of facility documentation, it was determined that the facility was not maintaining an effective pest control program.

Findings include:

Interview with Resident R8 in Room 105, on April 1, 2024, at 11:40 a.m. revealed that the resident had often seen mice in the facility.

Interview with Resident R9 in Room 108, on April 1, 2024, at 11:43 a.m. revealed that the resident had often seen mice in the facility, and the exterminator too.

Interview with Resident R10 in Room 108, on April 1, 2024, at 11:45 a.m. revealed that the resident saw mice in the facility in the past.

Interview with Resident R11 in Room 113, on April 1, 2024, at 11:50 a.m. revealed that the resident often had seen mice and roaches in the facility, the mice run from room to room. "I stomped my foot and they don't even run away, just look at you."

Interview with Resident R12 in Room 115, on April 1, 2024, at 11:00 a.m. revealed that the resident had seen mice in the facility and roaches in the bathroom.

A brief review of the third-floor pest logs at the facility revealed mice sighting as follows:

November 23, 2023 - mice in fridge in med room on 1 North
December 4, 2023 - roaches in ice machine
January 11, 2024 - mice in administrators office
January 11, 2024 - mice sighted in room 267
February 26, 2024 - resident caught 4 mice in room 102
March 2, 2924 - mice in dining room on 2 North
March 4, 2024 - mice in room 203 and 204

A brief review of the pest management company reports revealed the following:

February 6, 2024, treated dietary kitchen are for mice and roach activity. Observed roach activity around stove top area.
March 26, 2024, recommend clearing out the patients on 2nd floor room 207 to do a proper roach treatment. room 207 bed A is cluttered and highly infected with roach activity. Treated kitchen, lobby, lounges, soiled utility and nurses station.

Interview with Nursing Home Administrator on April 2, 2024 at 2:05 p.m. confimed the information in the logs and reports.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Coe 201.18(b)(3) Management




 Plan of Correction - To be completed: 04/24/2024

Facility will consult new pest control company to maintain an effective program.
All rooms identified were checked and treated as indicated.

NHA or designee will audit pest log to ensure proper treatment weekly x3 for 2 months. All finding will be brought to our monthly QAPI meeting.

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