Incomplete Investigation of Resident Elopement
Penalty
Summary
Burgh Care Center was found non-compliant with federal and state regulations due to a failure to fully investigate an incident involving a resident's unauthorized leave of absence. The facility's policy required all incidents to be thoroughly investigated and reported, including witness accounts. However, the investigation into the incident involving a resident who left the facility without authorization was incomplete. The resident, who had a history of opioid, alcohol, and psychoactive substance abuse, as well as a cerebral infarction, left the facility dressed in street clothes and was last seen heading towards a bus stop. Despite the facility's efforts to locate the resident, including searching the area and contacting a previous residence, the investigation did not include statements from all relevant witnesses, such as another resident and staff members who observed the incident. The Director of Nursing confirmed that the facility did not fully investigate the incident to rule out neglect. The report highlights that the facility failed to obtain witness statements from key individuals, including a dietary aide and a registered nurse supervisor, who were present during the incident. Additionally, the elopement risk screening tool used by the facility relied solely on nursing judgment, which may have contributed to the oversight. This lack of thorough investigation and documentation was a significant factor in the facility's non-compliance with the requirements for investigating and preventing potential abuse or neglect.
Plan Of Correction
Burgh Care Center acknowledges receipt of the Statement of Deficiencies and proposes this Plan of Correction to the extent that the summary of findings is factually correct and to maintain compliance with applicable rules and provisions of quality of care of residents. The Plan of Correction is submitted as a written allegation of compliance. Burgh Care Center's response to this Statement of Deficiencies does not denote agreement with the Statement of Deficiencies nor does it constitute an admission that any deficiency is accurate. Further, Burgh Care Center reserves the right to refute any of the deficiencies on this Statement of Deficiencies through Informal Dispute Resolution, formal appeal procedure and/or any other administrative or legal proceeding. F- 610 Investigate/Prevent/Correct Alleged Violation 1. Elopement Procedure was implemented by the Director of Nursing to search for the resident on 2/25/25. Event Report submitted to DOH by the Administrator on 2-26-25. Physician, Police, and Area Agency on Aging were notified by the Administrator on 2/25/25. Statements were gathered from the staff and residents by the Administrator on 2/25/25 and 2/26/25. The Elopement Book was updated by the Director of Nurses by 2/25/25. A Root Cause Analysis was completed by the Administrator on 2/26/25. Elopement Drills were conducted on each shift by the Human Resources Director by 2/28/25. The staff was educated on the Elopement Policy and Procedure by the Human Resources Director started on 2/25/25. The elopement assessment was rewritten by the Regional Clinical Director and Director of Nursing on March 13, 2025. The Resident LOA Policy was updated on March 13, 2025, by the Administrator to include a system requiring the orders are reviewed before allowing the residents to leave the facility. An Ad Hoc QAPI Meeting was held by the Administrator on 2/25/25. 2. A revised elopement Assessment was completed on each resident by the Director of Nursing and Assistant Director of Nursing on 3/13/25. 3. The Resident LOA Policy was updated on March 13, 2025, to include a system requiring that the orders are reviewed before allowing the residents to leave the facility. An audit will be completed on each new admission by the Administrator or designee to assess each resident against the four risk factors identified in the Root Cause Analysis. These audits will be completed weekly for 3 weeks then monthly for 2 months. An audit will be completed by the Director of Nurses or designee to ensure that the elopement assessments have been completed for new admissions, readmissions, quarterly, and change of condition. These audits will be completed weekly for 3 weeks then monthly for 2 months. Audits will be completed by the Administrator or designee to ensure the LOA policy change is being properly implemented. This will be completed weekly for 3 weeks then monthly for 2 months. 4. A summary of the audits will be reviewed in the monthly QAPI meeting for 2 months.