The NHA and DON failed to manage the facility effectively to protect a resident known to be at risk for elopement. A resident exited the assigned nursing unit unsupervised, and the report states this created an Immediate Jeopardy situation for one of fourteen residents documented as elopement risks. The NHA and DON confirmed the administrative failure during interview.
Failure to Ensure Supervision and Elopement Prevention: The facility failed to consistently supervise and maintain safety interventions to prevent elopement for residents. Review of records, job descriptions, and staff interviews showed the NHA and DON did not effectively manage the facility to ensure proper supervision and elopement prevention interventions were implemented, and they failed to fulfill their essential duties to ensure federal and state guidelines and regulations were followed.
Failure to Prevent and Investigate Resident Elopement: The NHA and DON did not ensure adequate supervision and interventions for a resident at risk for elopement. The resident eloped through an unlocked and unalarmed exit door, and later observations found the same door was still not locked, alarmed, or monitored. Facility documentation did not identify who found the resident or where she was located, and the DON stated the facility did not obtain details from police or the ambulance company involved in returning the resident.
The NHA and DON failed to effectively manage the facility when two residents developed avoidable Stage III or Stage IV pressure ulcers due to extensive noncompliance in pressure ulcer care. The facility did not ensure proper preventative wound care or wound treatments, and one resident also developed a wound infection. The deficiency was cited as an IJ.
The NHA and DON failed to effectively manage the facility when a staff member saw a man enter with a shotgun and ammunition in his hand. The report states this created an Immediate Jeopardy situation for all residents and cites the NHA and DON for failing to ensure a safe environment free of accidents likely to cause serious injury, harm, impairment, or death.
The NHA and former DON failed to implement procedures to ensure prescribed medications were available. As a result, a resident ordered IV antibiotics was rehospitalized to receive the medication, and the report states this created an Immediate Jeopardy situation for four of 25 residents who did not receive medications.
Failure to Manage Resident Leave of Absence Safely: The Former NHA and DON failed to effectively manage the facility when a resident was allowed to leave unsupervised in approximately 95-degree weather and developed heat stroke. The report states this created an immediate jeopardy situation for 37 residents approved for LOA, and that management failed to ensure federal and state requirements and facility policies were followed.
The NHA and DON failed to manage the facility effectively to ensure allegations of abuse were reported timely and that interventions were implemented to protect residents from abuse. Review of job descriptions, facility documentation, and staff interviews showed the facility did not meet its responsibilities to protect residents from potential abuse, resulting in an Immediate Jeopardy situation.
Failure to Monitor Wandering and Elopement Safety Systems: The NHA and DON did not effectively oversee systems intended to protect a resident at risk for wandering/elopement. A resident with a history of removing an electronic monitoring device and expressing intent to leave, smoke, and return home exited through an exterior door without staff knowledge or supervision and entered an unsafe outdoor environment.
Failure to prevent resident elopement occurred when the NHA and DON did not effectively manage the facility to protect residents from exiting unsupervised, and a resident left the building without supervision. The report states this created an Immediate Jeopardy situation for one of 29 cognitively impaired residents.
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