Citations in Florida
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Florida.
Statistics for Florida (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Florida
Surveyors identified that the facility did not maintain required documentation for 1.5-hour load bank testing, monthly generator load testing, weekly voltage checks, or monthly conductance testing for generator batteries. These omissions were confirmed during a record review and acknowledged by facility leadership.
Surveyors identified that the facility's Emergency Preparedness Program lacked required contact information for all staff and residents' physicians in its communication plan. The Administrator acknowledged these omissions during the review, and the findings were discussed with facility leadership.
Surveyors found that the facility's Emergency Preparedness Program listed satellite phones as an alternate means of communication, but the facility was unable to produce a satellite phone for inspection when requested. The Administrator confirmed that the alternate communication device was not available as required.
Surveyors found that two delayed egress exit doors lacked the required signage with a contrasting background, and one door in the Service Hallway automatically reset when tested, both in violation of NFPA 101 standards. These deficiencies were observed during a fire safety tour and acknowledged by facility leadership.
The facility did not complete required sensitivity testing for all smoke and duct detectors as mandated by NFPA 101 and NFPA 72. Record review revealed that 11 smoke detectors and two duct detectors were not tested, and inspection reports lacked documentation of sensitivity testing results. The Regional Maintenance Director acknowledged these findings during the survey.
Surveyors found that the Main Lobby had mixed sprinkler coverage, with two quick response and two standard sprinklers, which does not comply with NFPA requirements. The Regional Maintenance Director acknowledged the issue during the inspection, and the deficiency was documented with photographic evidence.
Surveyors found that a medication refrigerator was not connected to a distinctly marked receptacle powered by the critical branch of the EES, as required by NFPA 99. Additionally, the facility failed to provide documentation for required maintenance and testing of the EES, including generator inspections and load exercises. These deficiencies were confirmed through observation, staff interviews, and record review, affecting all residents receiving refrigerated medications and those dependent on emergency power systems.
A resident with significant self-care limitations due to recent surgery and left-sided impairment reported long delays in call-light response and dissatisfaction with ADL care. Despite communicating these concerns to staff and family members reporting issues to the Administrator, no grievance documentation was found, and the facility failed to demonstrate a response to the resident's complaints as required by regulation.
A resident was found to have a vascular access device in place for eleven days without any physician orders for its care, maintenance, or removal. Nursing staff did not document or communicate the presence of the device, and no orders were obtained until prompted by surveyors. The device remained unused, and the resident was unaware of its purpose during their stay.
A resident had a line in place in the left upper arm for eleven days without a physician's order for its removal or care, and staff failed to notify the DON or physician or document the line in the care plan or progress notes. The line remained in place and unused, with visible discoloration at the site, and an order for removal was only obtained after surveyor inquiry.
Failure to Maintain and Document Essential Electrical System Testing
Penalty
Summary
The facility failed to maintain the Essential Electrical System (EES) in accordance with NFPA 99 requirements, as evidenced by missing documentation and incomplete testing records. During a record review with the Regional Director of Plant Operations, surveyors found that there was no documentation for the required 1.5-hour load bank testing for 2024, nor was there evidence of monthly testing under a thirty percent load. This testing is necessary to ensure the generator can supply emergency power as required by regulation. Additionally, the facility did not provide documentation of weekly voltage checks for the two generator batteries. Regular monitoring of battery voltage is essential to confirm that the generator will function properly in the event of a power outage. The absence of these records indicates that the facility did not consistently monitor the generator batteries as required. Furthermore, there was no documentation of monthly conductance testing for the generator's two sealed batteries prior to 2025. Conductance testing is a standard procedure to assess the health and reliability of the batteries that support the emergency power system. The Regional Maintenance Director acknowledged these findings during the survey, and the deficiencies were reviewed with both the Administrator and the Regional Maintenance Director at the exit conference.
Plan Of Correction
Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in and will be conducted annually, with the next and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. An unannounced Fire & Life Safety Recertification survey was conducted on at Nspire Healthcare Tamarac, a nursing home in Tamarac, Florida. Nspire Healthcare Tamarac is not in compliance with 42 CFR 483 Subpart B, 42 CFR 488.307, and National Fire Protection Association (NFPA) 101 (2012 Edition), NFPA 99 (2012 Edition) requirements for nursing homes. Initial Plan Review. 1994 Existing NFPA 220 Construction Type: II (111) Number of beds: 151 Census: 122 The following is a description of the noncompliance. Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in and will be conducted annually, with the next and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. [Repeated sections with placeholders such as [R] and incomplete dates are included as in the original text.]
Incomplete Emergency Preparedness Communication Plan
Penalty
Summary
During a review of the facility's Emergency Preparedness Program (EP), surveyors found that the facility did not maintain a complete communication plan as required by federal regulations. Specifically, the communication plan was missing contact information for all staff members and for residents' physicians. This omission was identified during a record review conducted with the facility Administrator. The deficiency was confirmed through both documentation review and an interview with the Administrator, who acknowledged the absence of the required contact information in the EP. The findings were also discussed with the Regional Maintenance Director during the exit conference. No information was provided in the report regarding specific residents or their medical conditions at the time of the deficiency. The focus of the deficiency was solely on the incomplete communication plan within the facility's emergency preparedness documentation.
Plan Of Correction
Corrective Action for Affected Residents: The Administrator added a phone list of all employees and primary physicians that attend the facility. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: Administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure all contacts are current. Monitoring / Quality Assurance: Emergency Preparedness Manual will be reviewed annually and findings submitted to QAPI. E0030 Corrective Action for Affected Residents: The Administrator added a phone list of all employees and primary physicians that attend the facility. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: Administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure all contacts are current. Monitoring / Quality Assurance: Emergency Preparedness Manual will be reviewed annually and findings submitted to QAPI. E0030
Failure to Provide Alternate Communication Device Listed in Emergency Plan
Penalty
Summary
During a Fire & Life Safety re-licensure survey, surveyors reviewed the facility's Emergency Preparedness Program (EP) and found that the facility had listed satellite phones as an alternate means of communication in their emergency plan. However, when requested, the facility was unable to produce a satellite phone for inspection. This deficiency was identified through both record review and staff interview, where the absence of the listed communication device was confirmed. The Administrator acknowledged the findings during the interview and at the exit conference, confirming that the alternate communication method described in the EP was not available as required by federal regulations. The deficiency specifically relates to the facility's failure to ensure that the alternate means of communication, as outlined in their emergency preparedness plan, was present and accessible for inspection.
Plan Of Correction
Corrective Action for Affected Residents: The administrator added an updated list of primary and alternate means of communication. The facility does not use satellite phones. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: The administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure primary and alternate means of communication for the facility are listed. Monitoring/Quality Assurance: The Emergency Preparedness Manual will be reviewed annually, and findings will be submitted to QAPI.
Deficient Delayed Egress Door Signage and Function
Penalty
Summary
Surveyors observed that the facility failed to maintain egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101 requirements. During a fire safety tour, it was found that two delayed egress exit doors—the first floor West Wing Rehabilitation Room door and the Service Hallway door—did not have the required signage with a contrasting background. This signage is necessary to comply with fire safety codes and to ensure that the doors are easily identifiable in an emergency. Additionally, the Service Hallway delayed egress exit door exhibited a malfunction during testing. Specifically, the door automatically reset when it was tested, which is not in accordance with the required operation for delayed egress doors. This issue could potentially interfere with the proper function of the delayed egress system, which is designed to allow safe evacuation during emergencies. The findings were confirmed through direct observation by surveyors and acknowledged by the Regional Maintenance Director during the inspection. The deficiency was reviewed with both the Administrator and the Regional Maintenance Director at the exit conference. Photographic evidence was obtained to document the observed issues. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified.
Failure to Complete Required Fire Alarm System Sensitivity Testing
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 101 and NFPA 72 standards. During a record review with the Regional Maintenance Director, it was found that the biennial smoke detector sensitivity testing did not include 11 out of 73 smoke detectors. Additionally, the repairs inspection report did not indicate that the smoke detectors were sensitivity tested, nor did it provide the results of such testing. The annual fire alarm report listed 23 duct detectors in the inventory, but the duct detector differential pressure testing documented 24 duct detectors tested, and the smoke detector sensitivity testing only included 22 duct detectors, leaving two duct detectors untested for sensitivity. These discrepancies were identified through a combination of record review and staff interviews. The Regional Maintenance Director acknowledged the findings during the review. The records failed to demonstrate that all required smoke and duct detectors underwent the necessary sensitivity testing as mandated by the applicable codes and standards. The deficiency affects all residents and staff in the affected smoke compartments, as the fire alarm system is a critical component of the facility's safety infrastructure. The findings were reviewed with both the Administrator and the Regional Maintenance Director at the exit conference, and photographic evidence was obtained to support the observations.
Plan Of Correction
Corrective Action for Affected Residents: All smoke detectors and duct detectors identified as not sensitivity tested or inconsistently documented will be addressed/tested. The facility will be coordinating with the licensed fire alarm vendor to: complete sensitivity testing on the 11 of 73 smoke detectors that were not tested during the biennial testing dated. Complete sensitivity testing on the two (2) duct detectors that were not included in prior sensitivity testing. Reconcile and correct discrepancies between: smoke detector sensitivity testing reports, duct detector differential pressure testing reports, and annual fire alarm inspection reports. Identification of Other Residents Potentially Affected: A 100% review of fire alarm testing records was conducted to ensure all devices are included and properly documented. Measures to Prevent Recurrence: Maintenance leadership will be re-educated on NFPA 72 sensitivity testing requirements and the importance of reconciling all fire alarm testing reports for consistency and completeness prior to acceptance. Monitoring / Quality Assurance: Annual testing will be verified by the Maintenance Director and reviewed by the Administrator during Life Safety reviews. Corrective Action for Affected Residents: The facility will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically, the two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected. Corrective Action for Affected Residents: All smoke detectors and duct detectors identified as not sensitivity tested or inconsistently documented will be addressed/tested. The facility will be coordinating with the licensed fire alarm vendor to: complete sensitivity testing on the 11 of 73 smoke detectors that were not tested during the biennial testing dated. Complete sensitivity testing on the two (2) duct detectors that were not included in prior sensitivity testing. Reconcile and correct discrepancies between: smoke detector sensitivity testing reports, duct detector differential pressure testing reports, and annual fire alarm inspection reports. Identification of Other Residents Potentially Affected: A 100% review of fire alarm testing records was conducted to ensure all devices are included and properly documented. Measures to Prevent Recurrence: Maintenance leadership will be re-educated on NFPA 72 sensitivity testing requirements and the importance of reconciling all fire alarm testing reports for consistency and completeness prior to acceptance. Monitoring / Quality Assurance: Annual testing will be verified by the Maintenance Director and reviewed by the Administrator during Life Safety reviews.
Deficiency in Sprinkler System Compliance
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system (AFSS) in accordance with NFPA 101 and related standards for one of twelve sampled smoke compartments. During a fire safety tour, surveyors observed that the Main Lobby contained mixed sprinkler coverage, with two of the four sprinklers being quick response and the other two being standard sprinklers. This observation was made in the presence of the Regional Maintenance Director, who acknowledged the findings at the time. The deficiency was identified through a combination of direct observation, record review, and staff interviews. The surveyors specifically noted the inconsistency in the type of sprinkler heads installed within the same area, which does not comply with the requirements set forth by NFPA 13 and NFPA 25. The issue was discussed with both the Administrator and the Regional Maintenance Director during the exit conference, and photographic evidence was obtained to document the condition. No information was provided in the report regarding any residents' medical history or their condition at the time of the deficiency. The deficiency was limited to the fire protection system in the Main Lobby smoke compartment, and the report did not mention any immediate consequences or incidents resulting from the mixed sprinkler coverage. The focus of the findings was on the facility's failure to ensure uniform and compliant sprinkler system installation and maintenance as required by applicable fire safety codes.
Plan Of Correction
Continued from page 4 By the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Corrective Action for Affected Residents: The facility will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. By the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI.
Medication Refrigerator Not Connected to Critical Branch and EES Maintenance Documentation Lacking
Penalty
Summary
The facility failed to ensure that electrical receptacles serving medication preparation areas, specifically those used for medication refrigerators, were connected to the critical branch of the Essential Electrical System (EES) and were not distinctly marked as required by NFPA 99. During a fire safety tour, it was observed that a medication refrigerator was not plugged into a receptacle powered by the critical branch, and the required distinctive color or marking was absent. This deficiency was acknowledged by the Regional Maintenance Director during the observation and was reviewed with facility leadership at the exit conference. Photographic evidence was obtained to document the finding. Additionally, the facility did not maintain proper documentation for the maintenance and testing of the EES, including the generator and associated equipment. Required records for weekly inspections, monthly load exercises, and other scheduled maintenance activities were not provided during the record review with the Regional Director of Plant Operations. The lack of documentation means that the facility could not demonstrate compliance with NFPA 99, NFPA 110, and related standards for ensuring the reliability of emergency power systems. These deficiencies affect all residents who receive refrigerated medications from the affected medication room, as well as all residents and staff who rely on the facility's emergency electrical systems. The findings were based on direct observation, staff interviews, and record reviews conducted by surveyors during the inspection.
Plan Of Correction
Corrective Action for Affected Residents: The room medication refrigerator will be correctly tied into critical branch breaker to ensure it is supplied by the critical branch of the essential electrical system along with a distinctly marked critical branch receptacle, ensuring uninterrupted power during normal and emergency conditions for residents receiving refrigerated medications. Identification of Other Residents Potentially Affected: The facility conducted a review of all medication refrigerators and receptacles supplied by the essential electrical system, including medication preparation areas, to verify proper connection to and identification of critical branch power. Measures to Prevent Recurrence: All medication refrigerators will be verified to be connected to and powered by the critical branch. The Maintenance Director was educated on NFPA 99 requirements related to essential electrical system branch identification and medication refrigeration power sources. Monitoring/Quality Assurance: Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: Weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in [date] and will be conducted annually, with the next test due [date], and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due [date], and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. Corrective Action for Affected Residents: The room medication refrigerator will be correctly tied into critical branch breaker to ensure it is supplied by the critical branch of the essential electrical system along with a distinctly marked critical branch receptacle, ensuring uninterrupted power during normal and emergency conditions for residents receiving refrigerated medications. Identification of Other Residents Potentially Affected: The facility conducted a review of all medication refrigerators and receptacles supplied by the essential electrical system, including medication preparation areas, to verify proper connection to and identification of critical branch power. Measures to Prevent Recurrence: All medication refrigerators will be verified to be connected to and powered by the critical branch. The Maintenance Director was educated on NFPA 99 requirements related to essential electrical system branch identification and medication refrigeration power sources. Monitoring/Quality Assurance: Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified.
Failure to Document and Respond to Resident Grievances Regarding Care Delays
Penalty
Summary
A deficiency was identified when the facility failed to provide evidence of documented grievances submitted by a resident regarding delays in call-light response and concerns related to activities of daily living (ADL) care. The resident, who was alert, oriented, and verbally responsive, had significant self-care limitations due to left-sided impairment and recent right-sided surgery. Her care plan required assistance with bathing, eating, hygiene, mobility, toileting, transfers, skin assessments, and the use of a call bell for help. Despite these needs, the resident reported waiting approximately four hours for assistance after activating her call light during nighttime hours and expressed dissatisfaction with the quality of care received upon admission. The resident stated that she communicated her concerns to nursing staff, but no improvements were observed. She also reported that certified nursing assistants (CNAs) told her they were responsible for 16 residents and did not have adequate time to provide timely care. The resident's family reported concerns to the Administrator but perceived the response as indifferent. Additionally, when the resident requested to receive ADL care before other residents due to her functional limitations, staff reportedly told her that permanent residents were prioritized over her. The administration did not address her complaints, and no documentation of her grievances was found. Interviews with staff revealed that while the resident's complaints were communicated to the Director of Nursing (DON) and documented in the facility's electronic system for other residents, no grievance documentation was submitted for this resident. The social worker confirmed that no grievance submissions were received from the resident and that there was no documentation indicating staff had submitted grievances on her behalf. The DON also stated that she had not received complaints from the resident or her family and described the facility's grievance procedure, which requires documentation and resolution within three days. However, no documentation existed for the resident's grievance, resulting in noncompliance with regulatory requirements.
Plan Of Correction
Resident #75 - grievances regarding ADL care and call light response were documented and addressed. A quality audit of current residents was conducted to ensure there are no undocumented grievances regarding delay in call light response and concerns related to activities of daily living (ADL) care. The Director of Nursing will educate the nursing staff on ensuring that grievances with residents' concerns are documented and addressed. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that staff is documenting grievances with residents' concerns. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly for 3 months or until substantial compliance has been met. per physician orders.
Failure to Obtain Physician Orders for Vascular Access Device Care and Removal
Penalty
Summary
A deficiency occurred when the facility failed to obtain physician orders for the care, maintenance, or removal of a vascular access device in a resident. Upon re-admission, the resident had a vascular access device in the left upper arm, which was observed to remain in place for eleven days without any documented physician orders for its care or discontinuance. The facility's policy required nurses to obtain and verify physician orders for such devices, including their removal, care, and maintenance, but this was not followed. Multiple observations confirmed the device remained in place, with visible brownish discoloration and a small, darkened area at the site. The resident reported not receiving any medication through the device since admission and was unaware of the reason for its continued presence. Review of the resident's medical records, including physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR), revealed no orders for the device's care, maintenance, or removal during the resident's stay. Interviews with nursing staff indicated a lack of awareness regarding the device's presence and the absence of any action to obtain necessary physician orders. The nurse who changed the dressing admitted to not notifying the oncoming nurse, the DON, or the physician about the device, stating she had forgotten to do so. There was no documentation in the nursing progress notes, baseline care plan, or comprehensive care plan regarding the device, and the physician was not contacted for orders until prompted by the surveyor.
Plan Of Correction
A quality audit of current residents was conducted to ensure that no ([R]) were noted without a physician order in place. The Director of Nursing educated licensed nurses on ensuring that a physician order is obtained for residents with ([R]) lines. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that a physician order is obtained for ([R]) residents with [R] lines. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Obtain Physician's Order and Document Care for Unused Line
Penalty
Summary
A resident had a line in place in the left upper arm for eleven days without a current physician's order for its discontinuance or for its care and maintenance. Multiple observations confirmed the line remained in place and was not in use, with the site showing brownish discoloration and a small, darkened area noted in the tubing. The physician's orders for the resident only included two oral medications, with no order for the line during the facility stay. Staff who identified the line did not notify the oncoming nurse, the DON, or the resident's physician to obtain appropriate orders for removal or care, stating she had forgotten to do so. There was no documentation in the nursing admission progress notes, ongoing nursing progress, baseline care plan, or comprehensive care plan regarding the identification or existence of the line. The physician's order to remove the line was only obtained after surveyor inquiry.
Some of the Latest Corrective Actions taken by Facilities in Florida
Staff Education & Communication Enhancements
- Provided comprehensive staff education on elopement policies, exit-seeking identification, alarm response and designated entry/exit procedures (J - F0689 - FL) (J - F0689 - FL) (J - F0600 - FL) (J - F0600 - FL)
- In-serviced licensed nurses on adding EMR elopement alerts, updating risk binders and completing new risk assessments (J - F0689 - FL)
- Trained receptionists to monitor door-alarm systems, review elopement binders each shift and document alarm activation/deactivation (J - F0689 - FL)
- Educated staff on resident supervision, leave-of-absence protocols, unauthorized-exit procedures and door-code confidentiality (J - F0689 - FL)
- Established shift-start huddles to review residents at risk for elopement or falls (J - F0689 - FL)
System, Equipment & Monitoring Improvements
- Disabled alarm mute function and increased annunciator volume on C-wing doors (J - F0689 - FL)
- Converted screamer annunciator to continuous alarm requiring a key to silence (J - F0689 - FL)
- Upgraded wander-alert device and repaired magnetic lock on fire exit door (J - F0689 - FL)
- Deactivated remote door releases to prevent unauthorized egress (J - F0689 - FL)
- Changed secure-unit keypad code and replaced push-button entry with keypad access (J - F0600 - FL)
- Issued visitor/vendor lanyards to distinguish them from residents (J - F0600 - FL)
- Instituted scheduled maintenance inspections of exit doors and wander-alert systems (daily initially, then weekly/monthly) (J - F0689 - FL) (J - F0600 - FL)
- Implemented daily wander-alert bracelet function checks documented on the Treatment Administration Record (J - F0689 - FL)
- Assigned reception staff to monitor main exits 8 AM–8 PM seven days a week (J - F0600 - FL)
- Initiated random audits of unauthorized exits, leave-of-absence status and elopement risk (J - F0689 - FL)
Failure to Honor and Document Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that advance directives were honored and properly documented in the medical records for three residents reviewed for code status. One resident, who had a documented preference for Do Not Resuscitate (DNR) status, was found unresponsive by staff and subsequently received cardiopulmonary resuscitation (CPR) both at the facility and during transport to the emergency room. Staff did not inform the Emergency Medical Team (EMT) of the resident's DNR status, and the required signed DNR Form DH1896 was not present in the resident's chart or provided to EMS. Interviews with staff revealed that although the resident returned from the hospital with a DNR order, the process to complete and file the official DNR form was not followed, and the form was never signed or placed in the chart. As a result, EMS initiated full resuscitation efforts, which were continued in the emergency department. Further review of two additional residents' records revealed similar documentation failures. One resident's chart contained both a full code order and a signed DNR form, leading to confusion about the resident's actual code status. Another resident's DNR form was signed by the provider but not by the resident or their representative, rendering the form invalid. Staff interviews confirmed that the process for verifying, documenting, and updating code status orders was inconsistently followed, and that required forms were either missing, incomplete, or not properly filed in the residents' medical records. The facility's policy required that code status and advance directives be verified on admission, documented in the medical record, and that the appropriate state-specific forms be completed and placed at the front of the resident's chart. However, the observed failures included lack of timely completion and filing of DNR forms, lack of communication with families or responsible parties to confirm code status changes, and the presence of conflicting orders in the medical record. These actions and inactions resulted in residents' wishes regarding resuscitation not being honored and created confusion among staff during emergency situations.
Removal Plan
- A house wide audit was completed verifying advanced directives and two identified variances were corrected. One code status was updated in the medical record, and it is clear to staff of the resident wishes and one next of kin validated the resident's advance directives with a signature.
- Regional Nurse Consultant provided education to 100% of the clinical management team related to Advanced Directives.
- Licensed Nurses were educated by the Director of Nursing and the facility clinical administration team related to Advanced Directives, reviewing AD/CS orders, process for completing a DNR order and honoring a resident choice, code blue process and placement of code status in resident hard chart at 97%.
- The Regional President completed the Essential Core Functions: Resident care and Quality of Life, Human Resources, Physical Environment and Atmosphere and Leadership and Management with the Nursing Home Administrator.
- The Director of Risk Management completed the Essential Core Functions: Resident Care and Quality of Life, Human Resources, Physical Environment and Atmosphere and Leadership and Management with the Director of Nursing.
- Code Blue drills started and completed each shift.
- ADHOC Quality Assurance meeting was conducted to review the removal plan including the medical director.
Failure to Properly Document and Maintain Advance Directives and DNR Orders
Penalty
Summary
The facility failed to ensure that Advance Directives, specifically Do Not Resuscitate (DNR) orders, were properly documented and maintained in the medical records for three residents. For one resident, there was no signed DNR Form DH1896 in the medical record, despite the resident returning from the hospital with a DNR status. Staff interviews revealed that although the change in code status was discussed and a verbal order was received, the required DNR form was never completed or signed by the appropriate parties, nor was it placed in the resident's chart. As a result, when the resident experienced a medical emergency, EMS was not provided with the valid DNR documentation, leading to the initiation of CPR against the resident's wishes as indicated by the verbal order and hospital documentation. Another resident's medical record contained both a full code order and a signed DNR Form DH1896, creating confusion regarding the resident's actual code status. Staff were observed to be uncertain about the resident's current status when reviewing the chart, as both orders were present and not properly updated. This improper documentation could have led to inappropriate interventions during a medical emergency. A third resident's DNR Form DH1896 was found to be incomplete, as it was signed by the provider but not by the resident or their representative, rendering the form invalid. Staff confirmed that the resident was capable of signing the form but was not asked to do so upon admission. The facility's policy required proper documentation and verification of Advance Directives, but these procedures were not followed, resulting in discrepancies and lack of clarity in residents' code status documentation.
Removal Plan
- A whole house audit was completed regarding advance directives and two identified variances were corrected.
- One code status was updated in the medical record, and it is clear to staff of the resident wishes and one next of kin validated the resident's advance directives with a signature.
- The Regional Nurse Consultant educated the clinical management team to the Code Status Response Policy.
- Licensed Nurses were educated by the Director of Nursing and the facility clinical administration team on Code Status Response Policy.
- The morning clinical worksheet was updated.
- ADHOC Quality Assurance meeting was conducted to review the removal plan including the medical director.
Failure to Follow Care Plan for Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when two CNAs failed to follow a resident's care plan, which required the use of a mechanical lift with two staff for all transfers. Instead, the CNAs manually lifted the resident from her wheelchair to her bed using a stand and pivot technique. During the transfer, the resident immediately complained of severe pain in her left leg and was subsequently lowered to the floor. The CNAs then manually lifted her from the floor and placed her in bed, but did not report the incident or the resident's pain to the nurse. The resident involved had a history of hemiplegia and hemiparesis following a stroke, obesity, chronic back pain, and muscle weakness, and was dependent on staff for all transfers. Her care plan and Kardex clearly indicated the need for a mechanical lift with two staff. Following the improper transfer, the resident experienced increased pain and was later found to have sustained a left proximal tibia fracture with mild displacement, as confirmed by X-ray. The resident's pain complaints increased significantly after the incident, and her functional status and mood declined, as documented in subsequent assessments. Both CNAs involved were unaware or disregarded the resident's transfer requirements, and neither reported the incident or the resident's pain to nursing staff. The resident did not receive immediate hospital evaluation for her injury, and there were delays in obtaining appropriate orthopedic follow-up. The failure to follow the resident's care plan for safe transfers resulted in a serious injury and avoidable pain, and placed other residents requiring mechanical lifts at risk for harm.
Removal Plan
- Resident was assessed by the nurse due to her complaint of pain in left lower extremity, provider was notified and order received for diagnostic imaging.
- Resident and roommate were interviewed by former DON and reported that resident was transferred without the use of the mechanical lift by two CNAs.
- The CNAs who were noted as failing to follow resident's plan of care correctly for use of mechanical lift were immediately suspended.
- The ADON began education on identifying resident's transfer status, safe transfers and skills validation.
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the facility Administrator, Director of Nursing and Medical Director to review the incident and training to be conducted as result of incident.
- The CNA who assisted the assigned CNA performed a reenactment of the incident and provided a statement which included information that the two CNAs had knowledge of resident's transfer status and subsequently disregarded this information by performing a stand and pivot transfer. Resident's care plan and Kardex indicated she required a two person assist with the use of mechanical lift for transfers.
- Each resident's care plan and Kardex were reviewed to ensure accurate transfer status was reflected.
- The facility held an ad hoc QAPI meeting to review the progress of education and competency completion as well as quality reviews. The committee conducted a root cause analysis which determined the assigned CNA made an independent decision, chose to ignore her prior education/training and did not follow the resident's plan of care for safe transfers. The ad hoc QAPI committee including the Medical Director approved the recommendations.
- The nursing staff were educated on change in condition to include but not limited to accidents resulting in injury, offering the resident to be transferred to higher level of care for further evaluation if serious injury, escalation to chain of command via nurse supervisor and/or DON if resident concern is not addressed, following resident care plan/Kardex, safe resident handing, mechanical lift usage and competencies. The remaining nursing staff members would receive education prior to next shift worked.
- Ad Hoc QAPI meetings were completed with Medical Director, Administrator, and former DON where incident, abuse and neglect, use of mechanical lifts, transfer competencies, updating care plans/Kardex, change in condition, pain management and following care plans/Kardex were discussed. No recommended changes were made to the performance improvement plan.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
Staff failed to protect a resident's right to be free from abuse and neglect by not following the resident's care plan for safe transfers. The resident, who had hemiplegia, hemiparesis, obesity, chronic lower back pain, and muscle weakness, was dependent on staff for transfers and required the use of a mechanical lift with assistance from two staff members. Despite this, two CNAs manually lifted and pivoted the resident from her wheelchair to her bed, disregarding the care plan and the presence of a mechanical lift sling already under the resident. During the manual transfer, the resident complained of severe pain in her left leg and was lowered to the floor. The CNAs then lifted her from the floor and placed her in bed without using the mechanical lift. The resident continued to express extreme pain, but neither CNA reported the incident or the resident's complaints to a nurse. The resident later informed another CNA of her pain, who reported it multiple times to an LPN, but the LPN did not assess the resident until nearly seven hours later. An X-ray performed the following day revealed a fractured tibia. The facility's investigation confirmed that the CNAs were aware of the resident's transfer requirements and chose to ignore them. The LPN also failed to respond promptly to the resident's complaints of pain. The actions and inactions of the CNAs and the LPN resulted in a serious injury to the resident and constituted neglect, as defined by the facility's policy. The incident placed not only the affected resident but also other residents requiring mechanical lifts at risk for serious harm.
Removal Plan
- Resident was assessed by the nurse due to her complaint of pain in left lower extremity, provider was notified and order received for diagnostic imaging.
- X-ray was performed and results were received which showed a proximal tibia fracture with mild displacement.
- Resident's physician was notified of the abnormal X-ray results and orders were received for a leg immobilizer and an outpatient orthopedic physician consult.
- A knee immobilizer was placed to resident's left leg as ordered.
- Resident and roommate were interviewed by the former DON and reported that resident was transferred without the use of the mechanical lift by two CNAs.
- The facility initiated an investigation.
- The ADON began education on identifying resident's transfer status, safe transfers and skills validation.
- An Ad Hoc QAPI meeting was held with the facility Administrator, Director of Nursing and Medical Director to review the incident including physician orders obtained related to the resident's fracture. Resident's individualized plan of care including outpatient orthopedic consult and leg immobilizer deemed appropriate by the Medical Director. Discussed staff training to be conducted as a result of incident.
- The CNA who assisted the assigned CNA performed a reenactment of the incident and provided a statement which included information that the two CNAs had knowledge of resident's transfer status and subsequent disregard by performing a stand and pivot transfer. Resident's care plan and Kardex indicated she required two person assistance with the use of mechanical lift for transfers.
- Each resident's care plan and Kardex were reviewed to ensure accurate transfer status was reflected.
- As part of the investigation process, residents were interviewed by the Social Services Director to determine if there were additional concerns of abuse or neglect with no findings.
- The facility held an ad hoc QAPI meeting to review the progress of education and competency completion as well as quality reviews. The committee conducted a root cause analysis which determined the assigned CNA made an independent decision, chose to ignore her prior education and did not follow the resident's plan of care for safe transfers. The ad hoc QAPI committee including the Medical Director approved the recommendations.
- Resident was seen by the provider. Her pain regime was reviewed and adjusted. The facility scheduled an orthopedic appointment as per the physician order.
- The former DON discussed transfer options to the hospital with resident.
- The former DON spoke to the resident and resident voiced wanting to go to the hospital.
- Resident was sent to the emergency room for evaluation due to uncontrolled pain related to the fracture. The resident returned to the facility.
- Resident's provider was contacted, and pain regimen was reviewed and adjusted.
- Nursing staff were educated on change in condition to include but not limited to accidents resulting in injury, offering resident to be transferred to higher level of care for further evaluation if serious injury, escalation to chain of command via nurse supervisor and/or DON if resident concern is not addressed, following resident care plan/Kardex, safe resident handing, mechanical lift usage and competencies. The remaining nursing staff members to receive education prior to next shift worked.
- Facility staff were educated on abuse, neglect and exploitation by the Administrator, Staff Development Coordinator and Nurse Managers. The remaining staff members to receive education prior to next shift worked.
- Ad Hoc QAPI meetings were completed with Medical Director, Administrator, and former DON where incident, abuse and neglect, use of mechanical lifts, transfer competencies, updating care plans/Kardex, change in condition, pain management and following care plans/Kardex were discussed. No recommended changes were made to the performance improvement plan.
Failure to Prevent Elopement Due to Lapses in Supervision, Communication, and Alarm System Functionality
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known risk for elopement exited the facility unsupervised through the main front door. The resident, who had diagnoses including dementia, memory deficit, cerebral infarction, atrial fibrillation, and diabetes, was found by police approximately half a mile away on a busy six-lane roadway after sunset. Facility staff were unaware that the resident had left the premises, and the resident was unable to communicate her address or destination to the police. The facility's policy required systematic monitoring and management of residents at risk for elopement, including timely response to alarms and implementation of care plan interventions, but these measures were not effectively executed. Interviews and record reviews revealed multiple lapses in supervision and communication. Staff members assigned to the resident did not know she was at risk for elopement, and no alarm or beeping sound was heard at the nurse's stations at the time of the incident. The care plan for the resident was not updated to reflect her elopement risk, and there were no interventions documented to address her behaviors of seeking to communicate with family or pacing near exit doors. Additionally, staff failed to redirect the resident or provide additional supervision when she expressed agitation and a desire to contact her daughter earlier in the day. Technical failures also contributed to the deficiency. The main lobby door's alarm system was not functioning as intended: the annunciator device on one wing was muted, and the other wing's device did not have a designated alarm switch for the main lobby door. Reception staff, who were responsible for monitoring the elopement risk binder and door alarms, were not aware of the resident's risk status. The front doors were left unattended and unlocked for a period in the evening, further compromising resident safety. These combined failures in supervision, communication, care planning, and alarm system functionality led to the resident's unsupervised exit and subsequent elopement.
Removal Plan
- Resident #1 returned to facility, placed on one-on-one supervision. Evaluation by LPN revealed no signs of injury or distress. Care Plan updated to reflect current care needs. A head count was conducted of current residents at the facility by RN supervisor. No concerns were identified.
- Current facility residents had elopement risk screens completed. Two additional residents triggered at risk for elopement. Orders and Care Plan were updated to reflect current needs based on updated Elopement Risk Evaluations.
- Elopement risk binders were reviewed to ensure they contain photos and demographic information of residents evaluated to be at risk for elopement. The surveyors reviewed and verified the 3 elopement binders located at the Receptionist desk, C Wing nurse's station and B Wing nurse's station were accurate.
- Elopement Drills to include door alarm drills conducted each shift. Education on elopement process, exit seeking behaviors and exit seeking behavior process/procedures discussed after each drill.
- Education for current staff initiated related to the facility Elopement/ Wandering Residents policy, Abuse, Neglect, Misappropriation and Exploitation, elopement/exit seeking behaviors identification, staff notification of elopement risk, location and contents of elopement risk binders, initiating enhanced supervision for residents actively exit seeking, responding to door alarms and proper actions to take once determined to be exit seeking or at risk for elopement. It also included the change to entry and exit of the facility through designated doors. Licensed nurses received specific education on exit seeking behavior and initiating appropriate care plan, orders and adding the elopement risk alert to the gray bar (this is in the electronic medical record and shows immediately below the picture of the resident in both the nurses charting system and the CNA charting system), immediately updating the elopement risk binders, creating a new elopement risk assessment in the computer and notifying nursing management. Receptionist received specific education followed by specific competencies on monitoring the door alarm system and notification to maintenance if a failure is identified, understanding the importance of the elopement binder and reviewing it at the beginning of each shift worked, and the proper procedures of resident LOA, signature for each oncoming and off-going shift on the clipboard indicating they had both appropriately initiated or deactivated the screamer alarm and for their review of the elopement binder, the process of utilizing the video doorbell for visitor/vendor entry and exit and notification of nursing manager if exit seeking behavior is identified.
- Education was conducted with IDT team on the process of identification, care planning, prevention, and response of elopement/exit seeking behaviors in morning meeting by progress/behavior note review and a review of the elopement risk UDAs, admission and readmission assessments (that contain the elopement risk evaluation for new residents) completed.
- Huddles are conducted at the beginning of each shift to discuss elopement risk and fall risk residents. This is an added communication to ensure staff are aware of at-risk residents.
- Door function and alarms were checked by the Administrator and the Maintenance Director, all doors and alarms were functioning appropriately. During the review by Maintenance Director, the C wing annunciator was noted to be muted. The volume of the annunciator was increased, and the button was disabled to remove the ability of staff to adjust the volume by vendor.
- Education provided by Staff Development Coordinator, DON and Administrator. All facility staff received education on the facility elopement/ Wandering Residents policy, Abuse, Neglect, Misappropriation and Exploitation, elopement/exit seeking behaviors identification, staff notification of elopement risk, location and contents of elopement risk binders, initiating enhanced supervision for residents actively exit seeking, responding to door alarms and proper actions to take once determined to be exit seeking or at risk for elopement. It also included the change to entry and exit of the facility through designated doors. All licensed nurses received education on exit seeking behavior and initiating appropriate care plan, orders and adding the elopement risk alert to the gray bar (this is in the electronic medical record and shows immediately below the picture of the resident in both the nurses charting system and the CNA charting system), immediately updating the elopement risk binders, creating a new elopement risk UDA and notifying nursing management. All receptionists have been educated on monitoring the door alarm system and notification to maintenance if a failure is identified, understanding the importance of the elopement binder and reviewing it at the beginning of each shift worked, and the proper procedures of resident LOA, signature for each oncoming and off-going shift on the clipboard indicating they had both appropriately initiated or deactivated the screamer alarm and for their review of the elopement binder, the process of utilizing the video doorbell for visitor/vendor entry and exit and notification of nursing manager if exit seeking behavior is identified.
- Newly hired staff and staff members on leave will receive education at orientation or prior to working their next scheduled shift.
- Root Cause Analysis (RCA) completed and reviewed by QAPI. Additional contributing root causes were identified and addressed in QAPI, as outlined below. These factors were staff response, staff knowledge of elopement risks and resident safety, appropriate plan of care/interventions for residents, muting of the C wing annunciator.
- The facility conducted an ad hoc QAPI meeting which included the Facility Administrator, DON, Medical Director via telephone, and additional staff members. The Performance Improvement Plan was accepted by the committee. The annunciator and the correction plan of the annunciator was reviewed in QAPI as indicated by the review of the maintenance enhancement plan. Door alarm annunciator volume increased on C wing, mute button on C wing annunciator disabled. Reviewed staff education completed including identification and response/process of exit seeking behaviors, elopement drills conducted. No additional recommendations were made at that time.
Failure to Ensure Nursing Staff Competency in Code Status Identification and Timely CPR Response
Penalty
Summary
Nursing staff failed to demonstrate competency in identifying a resident's code status, providing timely CPR, and responding appropriately to a change in condition for one resident. The resident, who had multiple complex diagnoses including metabolic encephalopathy, multiple sclerosis, sepsis, acute respiratory failure with hypoxia, and was cognitively intact, experienced a significant drop in oxygen saturation to 84% while on supplemental oxygen. Despite this abnormal reading, the LPN on duty did not notify the medical provider or document any interventions regarding the change in condition. Later, the resident was found pulseless and not breathing. There was confusion among the nursing staff regarding the resident's code status due to conflicting documentation between the hospital transfer form, which indicated DNR, and the facility's electronic health record and care plan, which indicated full code. The LPN and other staff delayed initiating CPR while attempting to clarify the code status, consulting with the DON and other supervisors, and paging hospice. This resulted in a delay of 45-60 minutes before chest compressions and ventilation were started, during which time the resident's wishes for CPR were not honored, and the resident died. Further review revealed that the LPN involved had incomplete orientation records, with no documentation of training on advanced directives, DNR orders, hospice care, respiratory care, vital signs, or change in condition protocols. The facility was unable to confirm whether another LPN had received the required training. Interviews with staff and review of facility policies indicated that prior to the incident, there was a lack of consistent staff training on code blue drills, advanced directives, and change in condition response, contributing to the deficiency.
Removal Plan
- An audit of each resident's code status was initiated and completed.
- The licensed nurse was suspended, pending investigation.
- An ADHOC Quality Improvement Performance Committee (QAPI) was conducted to review recommendations from the root cause analysis.
- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
- Code blue drills were initiated on multiple shifts and will continue until all staff have completed, with results reported to the QAPI committee.
- The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR, with a posttest upon completion.
- Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
- 100% of staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
- Licensed nurses received education on the identification of a change in condition including competency.
- The Human Resource Director will ensure during new hire orientation, newly hired nurses and CNAs are educated on the facility policy related to advanced directives, CPR, and the completed road map from orientation will be signed acknowledging the education received.
- Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
Failure to Provide Timely CPR and Notify Physician of Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to provide timely Cardiopulmonary Resuscitation (CPR) to a resident who was found pulseless and not breathing, despite the resident having a documented full code status and no valid Do Not Resuscitate (DNR) order in the medical record. The LPN on duty observed a significant drop in the resident's oxygen saturation to 84% with supplemental oxygen but did not notify the medical provider or document any interventions regarding this change in condition. Later, when the resident was found unresponsive, there was confusion among staff regarding the resident's code status due to conflicting documentation between the hospital transfer form and the facility's records. Multiple staff members, including LPNs and CNAs, reviewed the resident's electronic health record and paper chart, confirming the absence of a DNR form and the presence of a full code order. Despite this, the LPN delayed initiating CPR, instead contacting facility administration, hospice, and the medical team, which resulted in a delay of approximately 45-60 minutes before chest compressions and ventilation were started. During this period, staff were uncertain about the appropriate course of action, and some began preparing for postmortem care before CPR was initiated. The resident had a complex medical history, including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes, pneumonia, acute kidney failure, myocardial infarct, and hypertension. The resident was cognitively intact and had previously expressed a desire to remain full code, as documented in care planning and social service notes. The failure to promptly notify the physician of the change in condition and to honor the resident's advance directive for full code status resulted in the resident's wishes for resuscitation not being honored.
Removal Plan
- An audit of each resident's code status was completed.
- The licensed nurse was suspended, pending the facility's investigation.
- A Quality Improvement Performance Committee (QAPI) was conducted to review recommendations from the root cause analysis.
- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
- Code blue drills were completed for all staff with results reported to the QAPI committee.
- The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR, with a posttest upon completion.
- Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
- Staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
- Licensed nurses received education on the identification of a change in condition including competency.
- Newly hired licensed nurses will receive education to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
- Ongoing training is being conducted for the identification of change in condition with competency.
Failure to Honor Advance Directives and Timely Initiate CPR
Penalty
Summary
The facility failed to ensure that a resident's advance directives were implemented in a timely manner and did not honor the resident's wishes regarding full code status. A resident with multiple serious diagnoses, including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes type 2, pneumonia, acute kidney failure, myocardial infarct, and hypertension, was documented as cognitively intact and had an active order for full code status. Despite this, when the resident's oxygen saturation dropped to 84% with supplemental oxygen, the LPN on duty did not notify the medical provider or document any interventions regarding this significant change in condition. Later, the resident was found pulseless and not breathing. There was confusion among staff regarding the resident's code status, as conflicting information was found between the hospital transfer form, which indicated DNR, and the facility's electronic health record, which indicated full code. Staff delayed initiating CPR for approximately 45-60 minutes while attempting to clarify the resident's code status, contacting administration, hospice, and the medical team instead of following the full code order present in the record. During this time, no resuscitative efforts were made, and the resident was ultimately pronounced dead. Interviews with staff revealed a lack of clarity and understanding regarding the process for verifying and acting on code status, as well as inconsistent documentation and communication. The facility's policy required that any changes to advance directives be properly documented and communicated, but this was not followed. The failure to promptly initiate CPR in accordance with the resident's documented wishes and physician orders resulted in the resident's wishes not being honored.
Removal Plan
- An audit of each resident's code status was completed.
- The licensed nurse was suspended, pending the facility's investigation.
- A Quality Improvement Performance Committee was conducted to review the recommendations from the root cause analysis.
- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
- Code blue drills were initiated on multiple shifts, with ongoing drills to continue until all staff have completed and with the results reported to the QAPI committee.
- The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR, with a posttest upon completion.
- Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
- Staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
- Licensed nurses received education on the identification of a change in condition including competency.
- Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
- Ongoing training is being conducted for the identification of change in condition with competency.
Failure to Prevent Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with a history of cognitive impairment, mild dementia, and alcohol use disorder exited the facility without staff knowledge or appropriate supervision. The resident, who was assessed as being at risk for elopement and had an electronic wander bracelet in place, was able to leave the facility by following another resident out the door, which was remotely opened by staff. The door alarm was triggered but subsequently disabled by another resident who knew the code, and no staff were present in the reception area to respond to the alarm or monitor the exit. The resident walked approximately 0.2 miles to a nearby hospital and was returned to the facility by law enforcement several hours later. Prior to the incident, the resident had demonstrated behaviors such as wandering, confusion, and expressing a desire to leave the facility. Documentation showed that the resident had a BIMS score indicating moderate cognitive impairment and was independently mobile with a walker. Staff and family interviews confirmed the resident's history of confusion, exit-seeking behavior, and lack of safety awareness. On the day of the incident, staff failed to provide adequate supervision, did not respond to the exit alarm, and allowed a situation where residents could access and disable the alarm system due to unsecured door codes. The facility's records revealed that the elopement was not documented in the abuse/neglect log or the incident and accident report. Staff interviews indicated a lack of awareness and response to the alarm, and video evidence confirmed that no staff were present in the area at the time of the exit. The resident's care plan included interventions for elopement risk, but these were not effectively implemented, resulting in the resident leaving the facility unsupervised and unnoticed for an extended period.
Removal Plan
- Resident #1 was put on enhanced supervision and then moved to the secure unit.
- An audit was completed by the DON and the facility's clinical administration team for current residents to ensure accuracy of assessment for cognition and mobility.
- Identified variances were corrected regarding LOA status.
- Staff were educated on the policy and procedures related to resident supervision, following procedures for residents leaving the facility for leave of absence, as well as the facility unauthorized exit protocols.
- Staff were educated by the DON and the facility clinical administration team on the door code process and the process to report unauthorized knowledge of the facility door codes.
- The remote door releases were deactivated.
- Code Silver drills were completed every shift.
- Random audits were completed regarding unauthorized exit, resident LOA status, and resident elopement risk.
- Ad hoc QA meeting was conducted to review the removal plan, which included the medical director.
Failure to Prevent Elopement Due to Inadequate Supervision and Alarm Issues
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with severe cognitive impairment from eloping. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and a cognitive communication deficit, was identified as an elopement risk and had a care plan in place that included an electronic wander alert bracelet and hourly rounding. Despite these interventions, the resident was able to exit the facility unsupervised during the early morning hours. Staff assigned to monitor the resident did not notice his absence until he was found outside the facility by another staff member arriving for work. Interviews with staff revealed that there were two CNAs and one nurse on duty at the time of the incident. The CNAs reported that they had asked the nurse to watch the residents while they assisted other residents, but the nurse left to administer medications, leaving the residents unsupervised. None of the staff on duty heard any door or wander alert alarms during the shift, and the resident's absence went unnoticed for an extended period. The resident was eventually found in the front vestibule of the facility by a staff member arriving for work, and staff on the unit were unaware he was missing until he was returned. A review of the resident's likely elopement route showed that he exited through a fire exit door, traversed various outdoor areas including a parking lot, a two-lane road, and landscaped beds, before entering the front vestibule. Along the way, he passed potential hazards such as an electric generator, commercial dumpsters, and a retention pond with an unlocked gate. The facility's elopement policy stated that alarms are meant to assist but do not replace necessary supervision, and the root cause analysis by the facility's QAPI Committee determined that staff failed to provide appropriate supervision, with alarm and door function issues also contributing to the incident.
Removal Plan
- Resident #1 returned to the secured unit with facility staff. He was assessed on return to the facility and had no injuries. A head count was conducted to verify the safety of all residents. The required notifications were made to the physician and family. Resident #1 was placed on one-to-one supervision.
- Patient Health Questionnaire (PHQ) evaluations were completed by the Licensed Clinical Social Worker for resident #1 for three consecutive days. Resident #1 did not exhibit any signs or symptoms of mental anguish or distress.
- Resident #1 was re-evaluated for elopement risk and the elopement risk care plan was updated.
- Employees were assigned to sit near the exit door on every shift until all the alarm settings and door functions were completed.
- A vendor was called and came in to assess the door and submit work order.
- The red screamer alarm annunciator was changed to alarm continuously until silenced by use of a key.
- All resident wander alert bracelets were checked for all residents identified as at risk for elopement and verified as functional.
- All residents were reassessed for elopement risk and re-evaluated.
- All elopement binders in place were reviewed by Registered Nurse (RN) Supervisor and found to be accurate with 23 residents identified as at risk for elopement. Elopement binders were updated with every new admission, new elopement assessment, discharge and as needed.
- All locations of the wander alert system were evaluated and found to be in working order.
- Maintenance Department staff audited wander alert system for functionality at all locations and conducted daily audits for one month and then weekly thereafter.
- Maintenance checked all doors to ensure they locked and latched; and audited the doors for functionality daily for week then weekly for three months then monthly thereafter.
- Care plans were reviewed for all residents identified to be at risk for elopement.
- Wander alert bracelets are checked daily for functioning and noted on the Treatment Administration Record.
- The facility conducted an elopement drill and continued daily drills on every shift. Elopement Drills were completed weekly on each shift.
- The maintenance team was educated by the Administrator to ensure doors functioned appropriately and if identified as dysfunctional to immediately initiate door monitoring process, notify the Administrator, DON and Operations Review Specialist and begin repairs as appropriate.
- Staff education began which included abuse, neglect, elopement policy and responding to alarms, and door alarm function. Remaining staff will be educated upon return from leave and are scheduled to work.
- The magnetic lock on the fire exit door was repaired.
- The elopement/wander alert device was upgraded on the identified fire exit door.
- All audits for corrective measures were reviewed in the Ad HOC QAPI meetings.
- All audits for corrective measures were reviewed in monthly QAPI and will be reviewed monthly for a minimum of three months or more until substantial compliance is achieved.
- Interviews were conducted with staff members representing all shifts. Staff interviews revealed they were knowledgeable of the elopement policy and procedures, appropriate response to alarms and supervision of all residents to include those at risk for elopement, abuse and neglect.
Failure to Prevent Elopement Due to Inadequate Supervision and Malfunctioning Alarms
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not ensuring staff maintained a secure environment and implemented measures to prevent elopement. A male resident with severe cognitive impairment, Alzheimer's disease, dementia, and a history of wandering was identified as an elopement risk and had interventions in place, including an electronic wander alert bracelet and hourly rounding. Despite these interventions, the resident was able to exit the facility unsupervised during the early morning hours, and his absence went unnoticed by staff for over two hours until he was found by staff arriving for the day shift. Interviews with staff revealed that there were lapses in supervision and communication. The CNAs and the LPN on duty were not fully aware of the resident's elopement risk or the need for specific supervision. The nurse assigned to the unit was an agency nurse unfamiliar with the residents and was not informed about the resident's exit-seeking behavior. Staff did not hear any alarms during the incident, and it was later discovered that the electronic wander alert system and door alarms were malfunctioning. Maintenance records confirmed that the alarm system at the relevant exit door had been out of order prior to the incident, and a vendor had been called for repairs, but no interim measures were put in place to monitor the door until after the elopement occurred. Documentation also showed that staff failed to complete required hourly rounding as indicated in the resident's care plan, with no evidence that rounds were conducted as instructed. The facility's own investigation and root cause analysis confirmed that inadequate supervision and failure to secure the fire exit door after the resident attempted to exit earlier in the shift contributed to the elopement. The lack of functioning alarms and insufficient staff awareness and supervision directly led to the resident's unsupervised exit from the facility.
Removal Plan
- Resident #1 was assessed on return to the facility and had no injuries. A head count was conducted to verify the safety of all residents. Resident #1 was placed on one-to-one supervision.
- Patient Health Questionnaire (PHQ) evaluations were completed by the Licensed Clinical Social Worker for resident #1 for three consecutive days. Resident #1 did not exhibit any signs or symptoms of mental anguish or distress.
- Employees were assigned to sit near the exit door on every shift until all the alarm settings and door functions were completed. The person designated to monitor the door had full view of the other two doors located on the secured unit.
- Hourly unit monitoring was initiated and facility management increased their presence on the floor.
- The facility conducted an elopement drill and continued daily drills on every shift. Elopement Drills were completed weekly on each shift.
- The maintenance team was educated by the Administrator to ensure doors functioned appropriately and if identified as dysfunctional to immediately initiate door monitoring process, notify the Nursing Home Administrator (NHA), DON and Operations Review Specialist and begin repairs as appropriate.
- Staff education began which included abuse, neglect, responding to alarms, resident monitoring/supervision and accountability. Education was provided to staff on a rolling basis until 95% of staff were educated. Remaining staff will be educated upon return from leave and are scheduled to work.
- All audits for corrective measures were reviewed in the Ad HOC QAPI meetings.
- All audits for corrective measures were reviewed in monthly QAPI meeting and will be reviewed monthly for a minimum of three months or more until substantial compliance is achieved.
- Staff interviews were conducted with 14 staff members representing all shifts to ensure knowledge of elopement policy and procedures, appropriate response to alarms and supervision of all residents to include those at risk for elopement, abuse and neglect.
- The resident sample was expanded during the survey to include four additional residents who were at risk for elopement. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations, care plans and physician orders for residents #8 through #11.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from neglect by not providing necessary supervision to prevent elopement. The resident, who had a history of Parkinson's Disease, cognitive impairment, and other significant medical conditions, was identified as being at risk for elopement and resided in a secured unit. Despite this, the resident was able to exit the facility undetected through the main entrance while the receptionist was distracted by visitors. The main entrance required manual unlocking after a buzzer was engaged, and the receptionist, responsible for monitoring the entrance camera, did not notice the resident leaving. There were no additional staff present at the entrance at the time of the incident. The resident's care plan and medical orders clearly indicated an elopement risk, and she was supposed to be provided with safe wandering interventions and supervision. On the day of the incident, the resident was last seen in the dining room and then was not found during medication pass and dinner. Staff initiated a search after realizing the resident was missing, but by that time, the resident had already left the building. The facility's layout allowed access from the secured unit to the main lobby and entrance through unsecured hallways, and the entrance system allowed visitors to enter without a code, though a code was required to exit. This system was in place at the time of the incident, and staff interviews confirmed that visitors could access the secured unit without a code, potentially allowing residents to leave unnoticed. The resident was found by law enforcement several hours later, approximately two miles from the facility, with minor injuries such as abrasions and bruising. She missed several doses of her prescribed medications during the period she was missing. Interviews with staff indicated that the resident had not previously exhibited exit-seeking behaviors and that staff were not aware of any immediate risk on the day of the incident. The failure to provide adequate supervision and effective security measures directly led to the resident's elopement and the resulting deficiency.
Removal Plan
- 100% headcount of residents was completed to ensure no other residents were missing. All other residents were accounted for.
- A whole house search of the facility was completed.
- The executive director was notified by the weekend supervisor who in turn notified facility managers to report to work to assist in the search. Regional and divisional staff were also notified and reported to the facility to assist in the search. The medical director and primary physician were notified.
- An external search of the community was initiated.
- Executive Director notified the local Police Department who assisted in the search.
- Upon return, the resident was placed on one-to-one supervision on the secured unit. (1:1 monitoring ordered).
- All facility exit door alarms and screamer devices were inspected by the Maintenance Director.
- Keypad code to secure unit was changed by the Maintenance Director.
- Immediate education on abuse neglect and exploitation and risk of elopement initiated.
- 3-11 shift sign-in sheet reviewed. 11-7 signage sheet reviewed. No concerns.
- The elopement risk assessments of all residents were reviewed for accuracy.
- An elopement drill was performed for the 11-7 shift.
- The resident was assessed by the nurse upon return and by the physician. Skin assessment done.
- An elopement drill was performed for the 7-3 shift.
- The care plans and kardexes of residents at risk for elopement were reviewed for accuracy.
- Visitor lanyards were ordered for identification of visitors/vendors to differentiate visitors from residents. The lanyards were put into use immediately.
- Keypad order to replace push button for entry to units. Keypad was installed.
- Elopement books were reviewed for accuracy.
- An ad hoc QAPI was performed by the facility IDT and reviewed by the Medical Director.
- The Executive Director initiated education related to abuse/neglect reporting.
- The Assistant Executive Director notified the Department of Children and Families of the elopement of Resident #1.
- A Federal Immediate Report was submitted.
- Current facility staff were provided education by the Director of Nursing and Assistant Director of Nursing pertaining to what constitutes resident mistreatment, abuse, neglect, and misappropriation of resident property. Any employees who have not received the training were notified they must receive the training prior to working their next scheduled shift. New employees hired after will receive education during the facility orientation process. Education pertaining to abuse/neglect is provided annually and as needed.
- Facility practices which assist in monitoring/identifying potential abuse and neglect include, but are not limited to: grievance process, complaints resolution process, facility theft and loss reporting, resident council, incident reporting, internal audits of resident trust accounts, daily staffing practices, and regular direct indirect supervision of nursing home employees and resident care by supervisory and administrative staff.
- Root cause analysis was performed by the regional director of clinical services related to the circumstances of the resident elopement. An IDT review and investigation of the residence episode of elopement was completed through the ad hoc copy process. Included in the investigation was reviewed the residence condition preadmission and post admission, resident evaluations including the accuracy of elopement evaluation resident care plan, staffing, facility environments and equipment.
- The residency elopement risk evaluation was completed accurately at the time of admission and a care plan for elopement risk was initiated. The resident was correctly placed on the locked [NAME] wing unit at the time of admission.
- The staffing PPD for licensed nurse assist and for CNA's. On the [NAME] Wing units on the 3:00 PM to 11:00 PM shift, there were two nurses and five CNA's for the 52 residents. 2 weeks staffing calculations (State only Requirement) reviewed with no concerns.
- Staff who predominantly work on the [NAME] Wing were interviewed via a questionnaire and asked if the resident displayed any exit seeking behaviors prior to the incident, verbalizations of wanting to leave, packing belongings, or pushing on exit doors. The staff report no indications of such desire to exit or knowledge of any exit seeking behavior.
- The investigation and root cause analysis revealed potential root cause scenarios (birthday party and push button entrance).
- Elopement risk evaluation facility systems processes in place related to patient identification of potential for elopement/ wandering and safety in place and followed.
- The elopement risk evaluation is completed on admission, quarterly, and after a significant change period the evaluation consists of ambulatory mobility status, wandering behaviors, cognitive status, and exit seeking indicators.
- If a patient is identified as a potential risk, based upon the evaluation, a patient identification form, which will include a current photo, a current description, and personalized care plans, and interventions, and redirection strategies. The patient elopement book contains copy of the patient identification form, a colored photo of the patient and a face sheet. The elopement books are maintained at each nursing station and at the entrance to the reception facility area.
- Facility door prevention maintenance, monitoring and checked for function weekly conducted as scheduled.
- All exit doors are inspected weekly.
- All designated entrance/exit areas have scheduled staff assigned to the receptionist area from 8:00 AM to 8:00 PM seven days a week.
- Staffing schedules are monitored daily by staffing coordinator and reviewed with executive director of nursing and or nursing supervisor on duty to ensure adequate staffing is maintained. Adequate staffing means all minimum PPD, and ratios are met and in addition, staffing is adjusted based on acuity of patient needs.
- All staff are screened prior to hire and a job specific orientation is performed. Receptionist not only receive training but have a completed competency on file.
- A review of five receptionist staff employees' file revealed all had completed training and had a competency on file. The receptionist on duty at the time of the residence elopement was suspended immediately and has subsequently been terminated.
- The maintenance staff performed an inspection of the facility exit doors and screamer devices and all were found to be fully functional.
- Weekly door checks by the Maintenance Director will be performed to ensure proper function. The push button entry system onto the memory care unit was replaced with the keypad the truth device.
- Facility licensed nurses completed a review of the accuracy of 185 current residents elopement risk evaluations. Of the 185 residents, 52 residents resided in the memory care unit and 51 of those who were already assessed to be at risk for elopement. The remaining 1 of 52 residents was originally placed on The [NAME] Wing unit for behavior management but has since become a risk for elopement. The residence assessment was updated to reflect the risk of elopement.
- The care plans and CNA Kardexs' of 52 of 52 residents at risk for elopement were reviewed. All were found to be in compliance with risk for elopement identified.
- Director of Nursing /designee to complete monitoring of new admission evaluations to ensure risk for elopement is accurately identified and care plan and Kardex are reflective of the risk, where appropriate.
- The Medical Director was informed of the citations and is in agreement with the removal plan.
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