Failure to Prevent Resident Elopement
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility, resulting in the elopement of a resident, identified as Resident R1. This incident created an immediate jeopardy situation for one of the five residents reviewed. The job descriptions for both the NHA and the DON clearly outline their responsibilities to manage the facility in accordance with federal, state, and local standards, and to ensure the highest degree of quality care is provided to residents at all times. However, their failure to prevent the elopement indicates a lapse in fulfilling these essential duties. During an interview conducted on February 11, 2025, at 1:13 p.m., both the NHA and the DON were informed of their failure to manage the facility effectively, which led to the elopement incident. The report cites specific Pennsylvania Code regulations that were not adhered to, highlighting the responsibility of the licensee and the management to ensure proper nursing services and overall facility management. The deficiency was identified as an immediate jeopardy situation, indicating a serious breach in the facility's duty to protect its residents.
Plan Of Correction
F-835 Administration 1. The elopement assessment was rewritten by the Regional Clinical Director and Director of Nursing on March 13, 2025. The resident elopement books were updated by the Administrator and Director of Nursing on March 13, 2025. The Resident LOA Policy was updated on March 13, 2025, to include a system requiring the orders are reviewed before allowing the residents to leave the facility. 2. A Root Cause Analysis was completed by the Administrator on March 13, 2025, which identified four risk factors for future elopements. 3. 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. The audits will be completed weekly 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. The Regional Director of Operations and the Regional Clinical Director will meet with the Administrator and Director of Nursing to review the audit results and discuss any new issues that may impact safety in the facility. These meetings will take place weekly for 3 weeks and then monthly for 2 weeks.