F0835

E

Failure of Administration to Prevent Elopement of High-Risk Residents

Kittanning, Pennsylvania Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

Facility administration, specifically the Nursing Home Administrator (NHA) and the Director of Nursing (DON), failed to effectively manage operations to protect residents identified as elopement risks from exiting the building unsupervised. The NHA job description required leading, guiding, and directing facility operations in accordance with local, state, and federal regulations and facility policies to provide appropriate care. The DON job description required planning, organizing, developing, and directing the overall operations of the nursing service department in accordance with applicable standards, regulations, and facility policies, as directed by the Administrator and Medical Director, to provide appropriate care and services to residents.

Despite these defined responsibilities, the NHA and the previously employed DON did not ensure that federal and state guidelines and regulations related to elopement prevention were followed. As a result, a resident who was a known elopement risk exited the building without supervision. This failure created an Immediate Jeopardy situation for 10 of 94 residents who were documented as elopement risks. During an interview, the NHA and current DON confirmed that facility administration failed to effectively manage the facility to protect residents from elopement. The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee, 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management, and 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.