Health inspection·October 5, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on facility policy review, clinical record review, and interviews with residents and staff, it was determined that the facility failed to implement a process to ensure effective safety measures to prevent elopement, prior to and following incident of resident elopement, for two of 26 residents reviewed who are permitted to go outside independently (Residents 1 and 2). This failure placed Residents 1 and 2 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings Include: Review of facility policy, titled Elopement, with a revision date of June 2023, revealed, It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the premises of the facility without the knowledge and supervision of facility staff .Post Elopement/upon return to the facility, the Director of Nursing Services or Charge Nurse shall: Examine the resident for injuries; Notify the Attending Physician; Notify the resident's responsible party of the incident; Complete and file an Incident Report; and Document the event in the resident's medical record. Any resident with a successful elopement will be reassessed and additional interventions will be identified and included with the Plan of Care. Review of facility policy titled, Signing Residents Out, revised March 2019, revealed, Each resident leaving the premises (excluding transfers/discharges) must be signed out. The duration of the LOA [Leave of Absence] must be communicated to the resident's charge nurse. Review of Resident 1's clinical record revealed diagnoses that included atrial fibrillation (Afib - an irregular, often rapid heart rate, that commonly causes poor blood flow), hypertension (elevated blood pressure), and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Further review of Resident 1's clinical record revealed a BIMS (brief interview for mental status) score on August 23, 2023, of 13 out of a possible 15, meaning Resident 1 is cognitively intact. Review of Resident 1's care plan revealed that he is at risk for injury/falls related to weakness, ambulatory dysfunction, and difficulty walking. This care area was initiated on June 2, 2021. Review of Resident 1's care plan also revealed that he experienced a fall on September 14, 2023. Further review of Resident 1's care plan revealed that he uses a single point cane for ambulation. This was noted to be effective August 24, 2021. Page 1 of 6 395428 395428 10/05/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Review of Resident 2's clinical record revealed diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), hypertension, atrial fibrillation, and history of falling. Further review of Resident 2's clinical record revealed a BIMS score on August 9, 2023, of 7 out of a possible 15, suggesting severe cognitive impairment. Residents Affected - Few Review of Resident 2's care plan revealed that she is at risk for falls/injury related to Alzheimer's dementia, history of falls, low back pain, and neuropathy (nerve damage or impairment that often affects the hands or feet). This care area was initiated March 10, 2021. Review of Employee 4's (Receptionist) statement, dated October 1, 2023, revealed, [Resident 1] + [Resident 2] were already sitting in the family room when I came in at 7:45. They sat till around 8:30 AM and their ride did not come. [Resident 1] got up and said I guess they aren't coming so, they went back to their room. At around 8:40 the car that picks them up came, didn't see them and left. [Resident 1] + [Resident 2] came back up + went outside - thought just going out for fresh air until Pastor of the church up the road called and said they were there and would have someone bring them back after the service. Marked it in the sign-out book. During an interview with Employee 4 on October 3, 2023, at 2:39 PM, she reiterated the above information. She confirmed that Resident 1 and 2 were on the list of residents who are considered safe to go outside independently. She revealed that she observed Residents 1 and 2 going outside sometime between 8:30 AM and 8:45 AM on October 1, 2023. She revealed that she was not certain of the actual time, but shortly thereafter she received a call from the Pastor at the nearby church. Additionally, she revealed that when the Pastor called to inform the facility that Residents 1 and 2 were there, he asked if they were permitted to stay for the service. Employee 4 stated that she told that Pastor that she assumed it was okay. Employee 4 revealed that she did not notify nursing staff of Resident 1's and Resident 2's whereabouts, or that they had walked to church. Employee 4 confirmed that she signed Residents 1 and 2 back in at 11:03 AM, when they were returned to the facility by a Parishioner. During an interview with Employee 3 (Registered Nurse) on October 3, 2023, at 2:06 PM, revealed that she was the house supervisor on October 1, 2023. Employee 3 revealed that, on that morning, she was was notified that there was a woman waiting there to talk to her. The woman (the Parishioner who returned Residents 1 and 2 to the facility) informed her that Residents 1 and 2 had been up to the church. Employee 3 stated that Residents 1 and 2 typically went to church every Sunday, so she didn't understand at that point that there was anything out of the ordinary. Employee 3 stated it was their normal routine to be out of the building on Sunday mornings. Employee 3 stated that she went ahead and assessed Residents 1 and 2 since they had been on LOA. Employee 3 stated that, once she realized that Residents 1 and 2 did not attend their normal church but instead walked to the neighboring church, she spoke to Resident 1 about the incident and asked him to inform staff if their ride does not come so that alternate transportation could be arranged. Employee 3 confirmed that she was not informed by Employee 4 that the Pastor had called the facility to notify them of Resident 1's and Resident 2's whereabouts. Employee 3 stated that she did not consider the incident an actual elopement. During an interview with Resident 1 on October 3, 2023, at 9:40 AM, he revealed that after his normal ride to church did not show, he and Resident 2 just went out and walked. We didn't let anyone know. We just pushed on until we found a church. Resident 1 stated that he did not think about the need to notify staff. He stated, We were in a lost position. We were in a land we weren't familiar with. 395428 Page 2 of 6 395428 10/05/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few It just happened. It was nothing that was planned. Resident 1 stated that he and Resident 2 used the roadway when walking to the church. During a later interview with Resident 1 on October 3, 2023, at 1:55 PM, Resident 1 stated that he did not recall if someone had educated him on not leaving the premises once he and Resident 2 returned from church. He stated, My memory is very, very bad. I don't control my memory. It controls me. Resident 1 also stated that he did not recall anyone ever informing him of where he can and can't go. He stated, If someone told me to not walk up the road, I wouldn't have walked up the road. Per googlemaps.com, the distance between the facility and the church was noted to be 0.5 miles. Observation of the roadway between the facility and the church on October 3, 2023, at 6:00 PM, revealed the speed limit to be 35 miles per hour. Additionally, observation revealed the roadway is utilized by a church, the facility, and a medical center. Review of Resident 1's and Resident 2's clinical record, including assessments, progress notes, and care plan, failed to reveal any notation of the elopement incident, evaluation/plan for safety, re-assessment of elopement risk, notification of the physician or responsible party, updated care plan interventions, or any documented re-education provided to Residents 1 or 2. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 3, 2023, at 1:01 PM, they revealed that they did not consider the October 1, 2023 incident involving Residents 1 and 2 as an elopement since less than 10 minutes had elapsed between the time Residents 1 and 2 were last seen and the time that the Pastor notified the facility of their whereabouts. They revealed that, consequently, they considered the incident as a LOA and, therefore, did not report the incident or treat it as an elopement following the event. The NHA and DON were provided the immediate jeopardy template on October 3, 2023, at 1:01 PM, and an immediate action plan was requested. On October 3, 2023, at 4:53 PM, the facility's immediate action plan was accepted, which included: 1. Staff member sent outside to sit with current Residents that are outside at 1320 (1:20 PM) on October 3, 2023. 2. Main entrance placed on lock down and the receptionist stationed at the front door. Receptionist manually opens door for all visitors, staff, and residents entering and exiting the facility. 3. Head count of all residents completed, all accounted for and safe. 4. Education to employees regarding Safe Outside List to be supervised at all times by a staff member. 5. [Resident 1's and Resident 2's] care plans have been updated to include verification of transportation to church weekly. 6. The above will be completed by 10/3/2023. On October 3, 2023, at 5:47 PM, the Immediate Jeopardy was lifted after ensuring that the immediate 395428 Page 3 of 6 395428 10/05/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0689 action plan had been implemented. Level of Harm - Immediate jeopardy to resident health or safety 28 Pa. Code 201.14(a) Responsibility of licensee Residents Affected - Few 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.18(a)(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395428 Page 4 of 6 395428 10/05/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on facility policy review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to report a resident elopement to the Department of Health as required for Residents 1 and 2. Findings Include: Review of facility policy, titled Elopement, with a revision date of June 2023, revealed, It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the premises of the facility without the knowledge and supervision of facility staff. Review of Employee 4's (Receptionist) statement, dated October 1, 2023, revealed, [Resident 1] + [Resident 2] were already sitting in the family room when I came in at 7:45. They sat till around 8:30 AM and their ride did not come. [Resident 1] got up and said I guess they aren't coming so, they went back to their room. At around 8:40 the car that picks them up came, didn't see them and left. [Resident 1] + [Resident 2] came back up + went outside - thought just going out for fresh air until Pastor of the church up the road called and said they were there and would have someone bring them back after the service. Marked it in the sign-out book. During an interview with Employee 4 on October 3, 2023, at 2:39 PM, she reiterated the above information. She confirmed that Residents 1 and 2 were on the list of residents who are considered safe to go outside independently. She revealed that she observed Residents 1 and 2 going outside sometime between 8:30 AM and 8:45 AM on October 1, 2023. She revealed that she was not certain of the actual time, but, shortly thereafter, she received a call from the Pastor at the nearby church informing the facility that Residents 1 and 2 were there. Employee 4 confirmed that she signed Residents 1 and 2 back in at 11:03 AM, when they were returned to the facility by a Parishioner. During an interview with Employee 3 (Registered Nurse) on October 3, 2023, at 2:06 PM, revealed that she was the house supervisor on October 1, 2023. Employee 3 revealed that, on that morning, she was was notified that there was a woman waiting there to talk to her. The woman (the Parishioner who returned Residents 1 and 2 to the facility) informed her that Resident 1 and 2 had been up to the church. Employee 3 stated that Residents 1 and 2 typically went to church every Sunday, so she didn't understand at that point that there was anything out of the ordinary. Employee 3 stated it was their normal routine to be out of the building on Sunday mornings. Employee 3 stated that she went ahead and assessed Residents 1 and 2 since they had been on LOA [Leave of Absence]. Employee 3 stated that, once she realized that Residents 1 and 2 did not attend their normal church but instead walked to the neighboring church, she spoke to Resident 1 about the incident and asked him to inform staff if their ride does not come so that alternate transportation could be arranged. Employee 3 confirmed that she was not informed by Employee 4 that the Pastor had called the facility to notify them of Resident 1's and Resident 2's whereabouts. Employee 3 stated that she did not consider the incident an actual elopement. During an interview with Resident 1 on October 3, 2023, at 9:40 AM, he revealed that, after his normal ride to church did not show, he and Resident 2 just went out and walked. We didn't let anyone 395428 Page 5 of 6 395428 10/05/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few know. We just pushed on until we found a church. Resident 1 stated that he did not think about the need to notify staff. He stated, We were in a lost position. We were in a land we weren't familiar with. It just happened. It was nothing that was planned. Resident 1 stated that he and Resident 2 used the roadway when walking to the church. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on October 3, 2023, at 1:01 PM, the NHA stated that, based on the facility policy, the facility did not feel the incident with Residents 1 and 2 was an elopement. He stated if they viewed this as an elopement, they would have reported it to the Pennsylvania Department of Health's Event Reporting System. 28 Pa. Code: 201.14(c) Responsibility of licensee 395428 Page 6 of 6