Emergency Preparedness Plan Lacked Strategies for At-Risk Residents
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness plan that addressed the resident population, specifically the needs of at-risk or vulnerable residents. During a record review and interview with the Maintenance Director and Administrator, it was found that the emergency preparedness plan did not include strategies for addressing the needs of these populations. The Administrator was unable to explain why the relevant policy was missing from the emergency preparedness binder. The deficiency affected all 120 residents in the facility. The facility was given an opportunity to submit the missing records by a specified deadline, but no records were received by the regulatory agency. The lack of documentation and planning for at-risk or vulnerable residents was directly observed during the survey process.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/08/2025, the Emergency Preparedness Plan was revised to include specific strategies addressing the needs of at-risk and vulnerable populations such as residents with cognitive impairments, limited mobility, and complex medical needs. 2. Identification of other residents having the potential to be affected was accomplished by: On 5/12/2025, the Interdisciplinary Team reviewed all resident records to determine which individuals were considered at-risk during an emergency. All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/25, the Emergency Plan was updated to include a section for identifying vulnerable residents, and care protocols were developed for each type of identified risk (e.g., evacuation assistance, medication needs). 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of the Emergency Preparedness Plan. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.