F0610

D

Failure to Conduct Thorough Investigation of Elopement-Related Incident

Jeannette, Pennsylvania Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The facility failed to initiate a thorough investigation of an elopement-related incident involving one resident. Facility policy dated 1/28/25 required staff to report, investigate, and review any accidents or incidents that occur or allegedly occur on facility property and may involve a resident. The resident, admitted on 10/18/24, had diagnoses including cardiomegaly, hyperlipidemia, and anxiety, and an MDS dated 1/18/26 showed a BIMS score of 13, indicating cognitive intactness. A progress note dated 2/17/26 at 11:36 a.m. documented that a RN was informed by rehab staff that the resident was outside in a wheelchair; upon assessment, the nurse found the resident outside with a newspaper and wallet in hand, stating he was trying to go to an appointment, and the resident was redirected back inside. Facility-provided documents contained only one witness statement from the DON, and during an interview on 3/20/26, the Nursing Home Administrator confirmed that the facility did not conduct a thorough elopement investigation for this incident as required by policy.

This deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of licensee, 28 Pa. Code: 201.18(b)(1)(3) Management, 28 Pa. Code: 211.10(d) Resident care policies, and 28 Pa. Code: 211.12(d)(3) Nursing services, based on the lack of a complete investigation into the resident’s elopement-related event despite policy requirements.