Pennsylvania Department of Health
GREENFIELD HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GREENFIELD HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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GREENFIELD HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Complaint Survey completed on May 24, 2024, it was determined that Greenfield Healthcare and Rehabilitation Center was not in compliance with the following Requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

51.3 (g)(1-14) LICENSURE NOTIFICATION:

51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based on review of the 28 PA Code Chapter 51 and clinical record, and staff interviews, it was determined that the facility failed to report an event related to elopement to the Department of Health (DOH) for one of one residents reviewed (Resident R1).

Findings include:

Review of the 28 PA Code Chapter 51.3 revealed:
(f) If a health care facility is aware of a situation or the occurrence of an event at the facility which could seriously compromise quality assurance or patient safety, the facility shall immediately notify the Department in writing.
(g) For purposes of subsections ... (f), events which seriously compromise quality assurance or patient safety include, but are not limited to, the following:
(4) Elopements.

Review of Resident R1's clinical record revealed an admission date of 7/20/23, with diagnoses that included vascular dementia (a disease that affects short term memory and the ability to think logically due to damage to the vessels in the brain), dysphagia (a disorder that affects the ability to speak and understand spoken words), and hypertension (high blood pressure).

Review of Resident R1's Minimum Data Set (MDS-periodic assessment of resident care needs) dated 2/9/24, revealed Resident R1's Brief Interview for Mental Status (BIMS) was coded as a level four with the coding range of 0-7 as severe impairment for cognitive status.

Review of Resident R1's physician orders revealed an order for wanderguard (alarming device to alert staff when a resident is in an unsafe location) to wheelchair, check placement and function every 24 hours as well as the expiration date.

Review of Resident R1's care plans revealed there was a care plan related to a focus of the resident as an elopement risk related to impaired safety awareness.

Review of Resident R1's clinical record revealed a progress note dated 5/5/24, that indicated Resident R1 exited the facility through the patio door; Resident R1's wheelchair was over the fence and Resident R1 was sitting on the ground attempting to elope the facility premises. There was no evidence that Department of Health (DOH) was notified of this incident where the resident exited a safe area without authorization.

During an interview on 5/22/24, at 12:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed the above incident occurred resulting in a resident leaving a safe area without authorization. They also confirmed that the Department of Health (DOH) was not notified of the incident that a resident left a safe area without authorization.

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 06/10/2024

For Resident R1 and all residents of the facility the following action plan will be initiated:
An Event Report was completed on the ERS for Resident R1 5/22/2024 for the incident that occurred 5/5/2024.
Education was provided by the Vice President of Clinical Services for the Administrator and Director of Nursing regarding the definition of elopement per PA guidelines and the need to report the incident to the Department of Health ERS.
Education regarding the definition of elopement and the need for reporting the incident to the Director of Nursing and or the Administrator was completed for the licensed nursing staff 5/22/24 by the Assistant Director of Nursing. DON provided education to the Assistant Director of Nursing.
Incidents were reviewed for the past 30 days and no unreported elopements were found.

An audit will be conducted weekly by the Director of Nursing to ensure that any incident of elopement will be reported to the Department of Health via the ERS. And will be monitored by the Administrator. Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be instituted.

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