§483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
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Observations:
Based on review of job's descriptions, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility to ensure that adequate supervisor was provided to one of 10 residents reviewed (Resident R1). This failure resulted in Resident R1 exiting the third floor via elevator and walking out the front entrance of the facility. Resident R1 was located two hours after the resident exited the facility approximately 1.2 miles away from the facility in a busy urban area. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1)
Findings include:
Review of the job description of the Nursing Home Administrator (NHA) revealed that, the primary purpose of the job position is to direct the day-day-day functions of the Center in accordance with current feferral, state, and local standards, guidelines and regualtions that govern nursing Centers to assure that the highest degree of quality of care can be provided to the residents at all times. "As Administrator, you are delegated the administrative authority, responsibility and accountability necessary for carrying out your assigned duties."
Review of the job description of the Director of Nursing (DON) revealed that, the primary purpose of the job description is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern the Center, and as may be directed by Administrator and the Medical Director, to ensure that the highest degrees of quality care is maintained at all times.
Review of Resident R1's clinical records revealed that the resident was admitted on January 15, 2025, with past medical history of repeated falls, difficulty walking, fracture of pelvic bone, and cognitive communication deficit.
Review of care plan for Resident R1 dated January 16, 2025, revealed that the resident was at risk for fall related to the history of fall with injury. Continued review of the care plan revealed that the resident required one person staff assistance for ambulation.
Review of physician order for Resident R1 from January 2025 through April 24, 2025, revealed no documented evidence that the resident had a physician order for leave of absence.
Review of facility investigation dated April 13, 2025, revealed that the nursing assistant assigned to the resident alerted the nurse that earlier in the shift, Resident R1 told her that the resident needed to walk, but the resident did not elaborate further. The nursing assistant at that time thought the resident was talking about walking on the unit. Later, in the shift when the nursing assistant went to the resident's room, she stated that the resident was not there. At this time the nursing assistant alerted the charge nurse, and a Code Yellow (Emergency protocol for Elopement) was announced. Further review of the investigation revealed that it was estimated that Resident R1 left the facility on April 13, 2025, at 3:53 p.m. through the front door. Resident R1 was appropriately dressed for the day and was ambulating with the roller walker. It was revealed that the resident arrived at a friend's apartment, the friend (who is also Resident R1 's emergency contact) was not home, however a neighbor who also knew Resident R1 contacted the friend who in turn notified the facility, The resident's friend confirmed that Resident R1 had arrived at her apartment to visit with her, but she was not home. Upon notification a nurse from the facility went to the apartment and picked up the resident and returned her to the facility at 6:30 p.m. Resident R1 stated that (she/he) was going to visit her friends in the community where (she/he) lived prior to (her/his) admission to the facility.
Review of a statement from Receptionist, Employee E9, dated April 13, 2025, revealed that a group of family members came downstairs off the elevator and right behind was an individual, well dressed with a purse in hand. The receptionist indicated that she was unaware that the individual was a resident of the building due to the individual being well dressed. Employee E9 stated she was think that the individual was just visiting a resident that lived in the facility. The individual was walking slow to the door however the person stopped at the carpet because the walker got caught up in the carpet. When employee looked up the individual was able to fix (herself/himself), after the individual walked out of the building.
Review of a statement from Registered Nurse Supervisor, Employee E9, dated April 13, 2025, revealed that at approximately 5:15 p.m., the assigned aide brought to her attention that Resident R1 was not in (her/his) room. The aide stated earlier resident mentioned that (she/he) needed to walk but she was not in (her/his) room. Employee E10 went out and bought the resident back to the facility.
A facility surveillance camera review was conducted with Employee E13, Regional Staff on April 24, 2025, at 10:43 a.m. revealed that on April 13, 2025, at 3:54 p.m. three visitors walked towards the front entrance, Resident R1 was walking approximately 6 feet behind the visitors. It was revealed that the Employee E9, who was the receptionist at the time, was doing personal shopping on the computer, she was scrolling the shopping website looking at the computer. Employee did not look at the resident when the resident first appeared in the camera. Employee opened the front door by pressing the button at the front desk. Then door closed before Resident R1 exited. Employee E9 looked up saw the resident and pressed the button to open the front door. Resident R1 was observed slowly walking out with a walker. It was also showed that the three family members did not wear a visitor badge nor sign out at the front which was the facility protocol for anyone exiting the facility. Employee E9 did not appear to ask the visitors or the resident to sign out or return the visitor badge.
Interview with Registered Nurse Supervisor, Employee E11, on April 24, 2025, at 12.18 p.m. stated after the resident was missing from the facility, she called resident's personal number and one of the staff from a senior living picked up the phone. Employee stated resident walked to the place. Employee drove her car to the place and picked up the resident ad brought the resident back to the facility. Registered Nurse Supervisor, Employee E11 also stated resident did not have an order for LOA and was not allowed to leave the facility premises unaccompanied.
Review of an internet map data revealed that the resident was located 1.2 miles away from the facility in a busy urban area. There were busy intersections, and multilane traffic through the route to the location.
Interview with Regional Vice President of Operations, Employee E14, on April 24, 2025, at 12.40 p.m. confirmed that Resident R1 did not have a physician order for LOA. Employee E14 confirmed that the resident should not have been allowed to leave the facility without proper supervision or physician order. Employee E14 also confirmed that Employee E9 had a clear view of the resident and still allowed the resident to leave without intervening. Employee E14 stated Employee E9 was not familiar with the resident thought it was a visitor. Employee E14 also confirmed that the facility did not follow the visitation protocol which would have helped distinguish between residents and visitors.
Interview with Employee E14, Employee E1, Nursing Home Administrator and Employee E2, Director of Nursing on April 24, 2025, at 12.40 p.m. confirmed that the facility non-compliance with LOA and visitation protocol placed Resident R1 at risk for serious injury.
Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and Regulations were followed, contributing to the Immediate Jeopardy situation.
Pa Code 201.14 (a)Responsibility of Licensee
Pa. Code 201.18 (a)Management
| | Plan of Correction - To be completed: 04/24/2025
"This Plan of correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction in not an admission or agreement with the deficiencies or conclusions contained in the Department's inspection report."
Resident has been re-educated on the LOA on the process and is not currently at risk of elopement from the center.
A full house audit was completed to identify any other residents similarly affected. All variances were updated and discussed with the physician. Care plans were updated to address safety and supervision. RDO reviewed with NHS/DON respective job descriptions. The job descriptions states that they will maintain and develop written policies and procedures that govern the operations of the center to include Resident Leave of Absence, Wandering and Elopements Procedure -Missing Resident.
RDO reviewed with LNHA and DON his/her respective job description which includes that the purpose of the position was to plan, organize, develop and direct the overall operation of the nursing services department in accordance with the current federal, state, and local standards, guidelines and regulations that govern our center and as may be directed by the NHA and MD to ensure the highest degree of quality care is maintained at all times. The NHA and DON delegates the administrative authority, responsibility and accountability necessary for carrying out assigned duties. RDO will complete weekly audits for 12 weeks to ensure administrative enforcement of visitor badge process is being adhered to.
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