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. The job descriptions for both the NHA and DON emphasize their responsibilities in ensuring adherence to policies and procedures, as well as having a thorough knowledge of federal and state regulations governing long-term care facilities. Despite these outlined duties, the facility did not prevent the elopement, which placed the residents in Immediate Jeopardy. The deficiency was identified through a review of job descriptions, clinical records, and staff interviews. During an interview, the NHA and DON were informed of their failure to manage the facility effectively to prevent the elopement. The report highlights that the NHA and DON did not fulfill their essential job duties to ensure compliance with federal and state guidelines and regulations, as evidenced by the elopement incident involving Resident R1.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Nursing Home Administrator and the Director of Nursing reviewed their job descriptions with the Human Resources Director, with a focus on the essential job functions. The Nursing Home Administrator completed her review on 4/30/2025. The Director of Nursing completed her review on 5/01/2025. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The Nursing Home Administrator and the Director of Nursing will attend the directed In-Service on 42 CFR 483.25 Accidents/Hazard/Supervision F689, which will be held on the week of May 5, 2025, by Masters crafted in Healthcare, LLC. This In-Service will include a review of all the federal regulations cited along with a review of the accompanying guidelines. The Elopement Assessment, Risk, and Prevention Policy was updated to include the definition of elopement. New policies were developed and implemented on Investigating and Reporting Accidents and Incidents, for both Administration and Nursing Staff. 3. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? The Nursing Home Administrator and Director of Nursing will continue to ensure that the new policies will be followed. This will be monitored at the daily Stand-Up Meetings, through audits of the electronic medical records. All will be reported quarterly at QAPI. 4. How will the corrective action be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? The Nursing Home Administrator and Director of Nursing are in attendance at each morning Stand-Up Meeting where resident specific issues and outcomes are reviewed. The Elopement Prevention Audit Tool, which includes physician orders, treatment record documentation, elopement binders, incident reports, hourly logbooks, event reporting, and physician notification is being completed by the DON or designee daily for 2 weeks starting on 4/16/2025, then weekly for 3 weeks, then monthly for 3 months, and then quarterly thereafter with the results reported to the Quality Assurance Committee for further follow-up. 5. Dates of when the corrective action will be completed - May 16, 2025.