F0689

K

Failure to Supervise Residents at Risk for Elopement, Self-Harm, and Choking

Reading, Pennsylvania Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and monitoring for residents identified as being at risk for elopement and self-harm. One resident with diagnoses including acute kidney failure, anxiety, depression, and a history of suicidal ideation was assessed as having no memory impairment and being able to walk independently. After this resident climbed out of a window by removing safety brackets, screws, and the screen, the physician ordered a Wander Guard and 1:1 supervision due to elopement risk, and the care plan reflected 1:1 observation and Wander Guard use. Despite this, clinical and behavioral notes over the following weeks documented ongoing agitation, irritability, mood changes, accusatory statements, suicidal thoughts, and passive death ideation, including statements about stabbing herself or overdosing, while the resident remained on ordered 1:1 observation.

On multiple occasions, the resident engaged in behavior indicating potential self-harm while 1:1 supervision was supposed to be in place. A nurse documented that the resident removed her Wander Guard while on 1:1 observation. Later, staff documented that the resident had two metal butter knives at her bedside, walked to an electrical outlet, and attempted to put the knives into the outlet while on 1:1 observation. A nurse aide’s written statement confirmed that the resident obtained butter knives and moved toward the outlet, and that later in the shift, while outside with other residents, the resident made a statement about wanting to harm herself. Subsequent psychology and psychiatry notes recorded continued suicidal thoughts, passive death ideation, and the resident’s admission that she had stuck knives in the outlet hoping to cause a fire so she could get out of the facility. On March 24, a Patient Watch Observation Sheet for this resident, who remained on 1:1 supervision due to destructive behavior, agitation, exit-seeking, and attempts to cause physical destruction, was observed on her dresser and was not completed, with no documented evidence that 1:1 supervision was in place at all times.

The facility also failed to maintain a safe environment to prevent elopement for another resident at risk. An employee exited through a hallway door marked as alarmed with instructions to keep it closed and propped it open. While the door remained propped open and unsupervised, a resident with nicotine dependence, cognitive communication deficit, and a care plan identifying elopement risk walked into the hallway by the open door and verbalized not knowing why he was there, not wanting to be there, and asking how he could get out. The door stayed open and unsupervised for approximately ten minutes, posing a safety risk for residents at risk for elopement.

In addition, the facility failed to provide adequate supervision and ordered interventions to prevent choking for a resident with dysphagia, schizophrenia, and dementia. This resident had memory impairment, required set-up assistance with eating, and could walk without assistance. Physician orders required staff monitoring during all meals and snacks to ensure the proper diet, a puree texture diet, and use of a sippy cup for all drinks with encouragement to drink slowly for choking prevention. Nursing and psychiatry documentation over several months showed repeated episodes of the resident taking food from other residents’ plates, trash cans, and medication carts, coughing episodes after consuming inappropriate foods such as sandwiches and peanut butter, and ongoing food-focused behaviors including pacing and repeatedly seeking food and fluids. One nurse note described the resident being found on the floor turning blue and coughing up a semi-chewed peanut butter sandwich, and another documented a choking episode in the dining room.

On March 19, facility documentation showed that the resident was observed in the dining room eating a peanut butter and jelly sandwich obtained from a cart left in the dining room, after which she alerted therapy staff that she did not feel well and was assessed by nursing to be choking, with drooling, cyanosis, and inability to speak. A Life Vac device was used to remove a large piece of sandwich. Subsequent observation on March 24 revealed that this resident was in the dining room drinking from a regular mug, and later was provided another regular mug with a beverage, rather than the ordered sippy cup. These observations demonstrated that the facility did not consistently provide the physician-ordered adaptive equipment or adequate supervision to prevent choking for this resident.