Other·July 15, 2025

REGULATION VIOLATION(S) 483.25 Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: (d) Accidents. The facility must ensure that - Based on observation, interview and record review, the facility failed to ensure supervision was (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. § 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. § 72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Findings: On 1/7/25 at 10:37 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an allegation of patient safety that occurred on 2/23/24. Based upon observation, interview, and record review, the department determined the facility failed to ensure adequate supervision to one patient (Patient 1) when Patient 1 was able to elope (the act of leaving a facility unsupervised and without prior authorization) from the facility undetected because the physician's ordered Wander Monitoring Device (WMD-a sensory device placed on patients that alarms if near a monitored exit) was not applied to Patient 1 by licensed nursing staff per the physician's order. The facility failed to do the following: * The facility failed to properly supervise Patient 1 who had a history of attempted elopement from the facility. * The facility failed to ensure that Patient 1 was using a WMD consistent with the doctor's orders to prevent the resident from eloping from the facility. These failures resulted in Patient 1 falling outside the facility and sustaining abrasions to his face and both knees and a fracture (a broken bone) to his left thumb. This failure also resulted in Patient 1 potentially sustaining additional harm if the resident was not located. A review of Patient 1's admission record indicated Patient 1 was admitted to the facility on 2/7/24 with diagnosis including cerebral infarction (stroke-loss of blood flow to the brain). A review of a Minimum Data Set (MDS-a federally mandated patient assessment tool) indicated Patient 1 had severe memory impairment and had impairment in both arms and legs requiring assistance with walking. A fall risk care plan dated 2/7/24 indicated Patient 1 was at high risk for falling related to his neuromuscular /functional problems following the stroke. A review of Patient 1's wandering risk assessment (WRA), dated 2/7/24, indicated Patient 1 was at low risk for wandering. A review of Patient 1's elopement care plan, initiated on 2/15/24, indicated, "[Patient 1 was an] Elopement risk r/t [related to] wandering around, trying to go outside or leaving facility...[Staff interventions listed included] Monitor for signs of elopement, leaving the facility or going outside without assistance...Q [every] 15 minute checks x [for] 72 hours...[Brand name Wander Monitoring Device] to be placed on RLE [right lower extremity]..." Further review of Patient 1's medical chart showed no additional WRA was conducted after Patient 1's elopement care plan was initiated nor after the initial 72-hour monitoring period lapsed. A review of Patient 1's physician's order dated 2/15/24 indicated, "Place [Brand name WMD] alarm (for elopement) and monitor for signs and symptoms of elopement, leaving the facility or going outside." A review of Patient 1's nursing progress note, dated 2/15/24 at 1:06 p.m., indicated, "[Patient 1 was]... confused, patient is a wandering person, would like to be in W/C [wheelchair] and propel self around facility, want to go home, patient try to elope facility to go home by self...Place wander guard on w/c & continues behavior monitor..." A review of Patient 1's nursing progress note dated 2/22/24 at 9:07 p.m., indicated, "[Patient 1]...with confusion...Kept trying to escape from the back door in their room saying he wants to go home. He is a high fall risk and needs constant monitoring for elopement...Will continue to monitor." A review of Patient 1's Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition in the patient) note dated 2/23/24 at 3:07 a.m., indicated, "...Elopement and fall on the street pavement...Alert but confused at times w/ [with] episode elopement. Wanting to go home. w/ episode ambulating w/ out using walker or assistive device...Abrasion to face and both knee w/ bleeding [Patient 1] was able to answer some question via translator. Denies pain except on the face...Called 911 [public emergency services]." A review of Patient 1's nursing progress note dated 2/23/24 at 4:38 a.m. indicated, "[At 12 a.m.] Went to check [patient] room and [patient] was not on [sic] the room...asked CNA to check [patient]...CNA came back and said she didn't see [patient]...went to look [for patient], per CNA in Station 2, [patient] pass by Station 2. Upon reaching the lobby this writer saw [patient] w/c left in the lobby. CNA...found [patient] lying down the street pavement outside facility, per CNA translator [patient] said he wants to go [sic] home. Called 911..." A review of Patient 1's x-ray result from the hospital, dated 2/23/24, indicated, "Acute [recent or sudden] fracture at the first distal phalanx [the bone at the tip of the thumb] through the proximal aspect [base of the thumb] with mild to moderate displacement [out of alignment]..." A review of Patient 1's nursing progress note dated 2/23/24 at 8:06 a.m., indicated, "[At 7:10 a.m.] ...returned from [hospital]...dressing to left thumb intact w/ swelling. Abrasion to face and both knee [sic] present w/ swelling on the face..." During an interview on 1/7/25 at 1:30 p.m., the Social Services Director (SSD) stated she remembered Patient 1 and he kept trying to leave the facility. The SSD stated Patient 1 was a high risk for elopement if he had a WMD ordered. During an interview on 1/7/25 at 2:01 p.m., the Director of Nursing (DON) agreed Patient 1's WRA was inaccurate, and he should have had a higher risk score since both an elopement care plan was initiated and a WMD had been ordered on the same day. The DON stated WMD's were typically placed on the patient's wrist or ankle and not placed on a patient's wheelchair. The DON stated the reason the WRD was not placed on Patient 1 should have been documented in the elopement care plan and confirmed it was not. The DON agreed Patient 1 was not adequately supervised and the facility was responsible for ensuring patient safety. The DON confirmed there was a breakdown in the system which resulted in Patient 1 eloping the facility on 2/23/24 without staff knowledge. During a review of an undated facility policy titled "Use of [WMD]" indicated, "...Wristband signaling device sets off alarm whenever it is in range of the door monitor...Ensure that [patients] at risk will wear the wristband by visual checking wristband every shift...Know which [patients] are at risk to wander and be careful to keep them away from doors..." During a review of a facility policy titled, "Safety and Supervision of Residents", dated 7/17, stipulated, "...[Patient] safety and supervision and assistance to prevent accidents are facility-wide priorities...Implementing interventions to reduce accident risks and hazards shall include the following...Ensuring that interventions are implemented...Monitoring the effectiveness of interventions shall include the following...Ensuring that interventions are implemented correctly and consistently..." The department determined the facility failed to ensure adequate supervision to Patient 1 when Patient 1 was able to elope from the facility undetected because the physician's ordered WMD was not applied to Patient 1 per the physician's order. These failures resulted in Patient 1 falling outside the facility and sustaining abrasions to his face and both knees and a fracture to his left thumb. This failure also resulted in Patient 1 potentially sustaining additional harm if the resident was not located. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.